Background
Microbiology
- Staphylococcus epidermidis and other coagulase-negative staphylococci
- Staphylococcus aureus
- Gram-negative bacilli, including Escherichia coli, Klebsiella, Proteus, Pseudomonas, and Acinetobacter
- Cutibacterium acnes
Clinical Presentation
- Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis 1
Diagnosis
- Gram stain and culture of CSF fluid from shunt aspiration, or from external ventricular drain that has a pleiocytosis
- Prolonged culture of 7-10 days
Management
- Empiric antimicrobials are typically indicated, with vancomycin plus an antipseudomonal such as ceftazidime or meropenem
- If seriously ill, target a vancomycin trough of 15 to 20 μg/mL
- Ciprofloxacin or aztreonam can be used in cases of β-lactam allergy
- Narrow based on culture results
- Removal of infected shunts, drains, intrathecal pumps, and deep brain stimulators is recommended
- Infected shunts should be removed and replaced with an EVD
- Cutibacterium acnes or coagulase-negative staphylococci
- No CSF abnormalities and negative cultures within 48 hours of externalization: reimplant as soon as the third day after removal
- CSF abnormalities but negative repeat cultures: reimplant after 7 days of antimicrobials
- CSF abnormalities and positive repeat cultures: reimplant after 7 to 10 days of negative cultures
- Staphylococcus aureus or Gram-negative bacilli: reimplant after 10 days of negative cultures
- Cutibacterium acnes or coagulase-negative staphylococci
First- and second-line antimicrobials by organism
Recommended antimicrobial dosages
| Antimicrobial | Children | Adults |
|---|---|---|
| amikacin | 22.5 mg/kg divided q8h | 15 mg/kg divided q8h |
| amphotericin B lipid complex | 5 mg/kg q24h | |
| ampicillin | 300-400 mg/kg divided q6h | 12 g divided q4h |
| aztreonam | 120 mg/kg divided q6-8h | 6-8 g divided q6-8h |
| cefepime | 150 mg/kg divided q8h | 6 g divided q8h |
| cefotaxime | 300 mg/kg divided q6-8h | 8-12 g divided q4-6h |
| ceftazidime | 200 mg/kg divided q8h | 6 g divided q8h |
| ceftriaxone | 100 mg/kg divided q12-24h | 4 g divided q12h |
| ciprofloxacin | 30 mg/kg divided q8-12h | 800-1200 mg divided q8-12h |
| daptomycin | 6-10 mg/kg divided q24h | |
| fluconazole | 12 mg/kg divided q24h | 400-800 mg divided q24h |
| gentamicin | 7.5 mg/kg divided q8h | 5 mg/kg divided q8h |
| linezolid | 30 mg/kg divided q8h (<12 years) 20 mg/kg divided q12h (≥12 years) |
1200 mg divided q12h |
| liposomal amphotericin B | 3-5 mg/kg divided q24h | |
| meropenem | 120 mg/kg divided q8h | 6 g divided q8h |
| moxifloxacin | 400 mg divided q24h | |
| nafcillin | 200 mg/kg divided q6h | 12 g divided q4h |
| oxacillin | 200 mg/kg divided q6h | 12 g divided q4h |
| penicillin G | 300,000 U/kg divided q4-6h | 24 million U divided q4h |
| posaconazole | 800 mg divided q6-12h | |
| rifampin | 20 mg/kg divided q24h | 600 mg divided q24h |
| tobramycin | 7.5 mg/kg divided q8h | 5 mg/kg divided q8h |
| TMP-SMX | 10-20 mg/kg divided q6-12h | |
| vancomycin | 60 mg/kg divided q6h | 30-60 mg/kg divided q8-12h |
| voriconazole | 16 mg/kg divided q12h | 8 mg/kg divided q12h |
References
- ^ Kirsten R.I.S. Dorresteijn, Korné Jellema, Diederik van de Beek, Matthijs C. Brouwer. Factors and measures predicting external CSF drain-associated ventriculitis. Neurology. 2019;93(22):964-972. doi:10.1212/wnl.0000000000008552.
