Ventriculitis: Difference between revisions

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==Background==
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== Clinical Presentation ==
  
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===Microbiology===
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* ''[[Staphylococcus epidermidis]]'' and other [[coagulase-negative staphylococci]]
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* ''[[Staphylococcus aureus]]''
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* Gram-negative bacilli, including ''[[Escherichia coli]]'', ''[[Klebsiella]]'', ''[[Proteus]]'', ''[[Pseudomonas]]'', and ''[[Acinetobacter]]''
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* ''[[Cutibacterium acnes]]''
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==Clinical Presentation==
 
* Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis [[CiteRef::dorresteijn2019fa]]
  
* Among patients with intraventricular drains, fever (72%) and elevated CSF cell count (93%) were most predictive of ventriculitis [[CiteRef::dorresteijn2019fa]]
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  +
==Diagnosis==
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* Gram stain and culture of CSF fluid from shunt aspiration, or from external ventricular drain that has a pleiocytosis
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** Prolonged culture of 7-10 days
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==Management==
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* Empiric antimicrobials are typically indicated, with [[Is treated by::vancomycin]] plus an [[antipseudomonal antibiotic]] such as [[Is treated by::ceftazidime]] or [[Is treated by::meropenem]]
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** If seriously ill, target a vancomycin trough of 15 to 20 μg/mL
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** [[Ciprofloxacin]] or [[aztreonam]] can be used in cases of β-lactam allergy
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* Narrow based on culture results
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* Removal of infected shunts, drains, intrathecal pumps, and deep brain stimulators is recommended
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* Infected shunts should be removed and replaced with an EVD
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** ''[[Cutibacterium acnes]]'' or [[coagulase-negative staphylococci]]
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*** No CSF abnormalities and negative cultures within 48 hours of externalization: reimplant as soon as the third day after removal
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*** CSF abnormalities but negative repeat cultures: reimplant after 7 days of antimicrobials
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*** CSF abnormalities and positive repeat cultures: reimplant after 7 to 10 days of negative cultures
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** ''[[Staphylococcus aureus]]'' or [[Gram-negative bacillus]]: reimplant after 10 days of negative cultures
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===First- and second-line antimicrobials by organism===
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{| class="wikitable sortable"
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! Organism
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! First-line
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! Second-line
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|-
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| ''[[Staphylococcus aureus]]'' (methicillin-susceptible) || [[nafcillin]] or [[oxacillin]] || [[vancomycin]]
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|-
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| ''[[Staphylococcus aureus]]'' (methicillin-resistant) || [[vancomycin]] || [[daptomycin]], [[TMP-SMX]], or [[linezolid]]
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|-
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| ''[[Streptococcus pneumoniae]]'' ([[penicillin]] MIC ≤0.06) || [[penicillin G]] || third-generation cephalosporin
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|-
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| ''[[Streptococcus pneumoniae]]'' ([[penicillin]] MIC ≥0.12) || third-generation cephalosporin || [[cefipime]] or [[meropenem]]
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|-
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| ''[[Streptococcus pneumoniae]]'' ([[ceftriaxone]] MIC ≥1) || [[vancomycin]] plus a third-generation cephalosporin || [[moxifloxacin]]
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|-
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| ''[[Pseudomonas aeruginosa]]'' || [[cefipime]], [[ceftazidime]], or [[meropenem]] || [[aztreonam]] or [[ciprofloxacin]]
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|-
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| ''[[Haemophilus influenzae]]'' (β-lactamase negative) || [[ampicillin]] || third-generation cephalosporin, [[cefepime]], or a fluoroquinolone
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|-
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| ''[[Haemophilus influenzae]]'' (β-lactamase positive) || third-generation cephalosporin || [[cefepime]], [[aztreonam]], or a fluoroquinolone
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|-
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| ESBL Gram-negative bacillus || [[meropenem]] || [[cefepime]] or a fluoroquinolone
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|-
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| ''[[Acinetobacter baumannii]]'' || [[meropenem]] || [[colistin]] or [[polymixin B]]
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|-
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| Other [[Enterobacteriaceae]] || third-generation cephalosporin || [[meropenem]], [[aztreonam]], [[TMP-SMX]], or [[ciprofloxacin]]
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|-
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| ''[[Candida]]'' species || liposomal [[amphotericin B]] ± [[flucytosine]] || [[fluconazole]] or [[voriconazole]]
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|-
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| ''[[Aspergillus]]'' species || [[voriconazole]] || liposomal [[amphotericin B]] or [[posaconazole]]
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|}
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===Recommended dosages===
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{| class="wikitable"
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! Antimicrobial !! Children !! Adults
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|-
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| [[amikacin]] || 22.5 mg/kg divided q8h || 15 mg/kg divided q8h
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|-
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| [[amphotericin B]] lipid complex || colspan=2 | 5 mg/kg q24h
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|-
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| [[ampicillin]] || 300-400 mg/kg divided q6h || 12 g divided q4h
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|-
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| [[aztreonam]] || 120 mg/kg divided q6-8h || 6-8 g divided q6-8h
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|-
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| [[cefepime]] || 150 mg/kg divided q8h || 6 g divided q8h
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|-
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| [[cefotaxime]] || 300 mg/kg divided q6-8h || 8-12 g divided q4-6h
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|-
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| [[ceftazidime]] || 200 mg/kg divided q8h || 6 g divided q8h
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|-
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| [[ceftriaxone]] || 100 mg/kg divided q12-24h || 4 g divided q12h
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|-
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| [[ciprofloxacin]] || 30 mg/kg divided q8-12h || 800-1200 mg divided q8-12h
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|-
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| [[daptomycin]] || || 6-10 mg/kg divided q24h
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|-
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| [[fluconazole]] || 12 mg/kg divided q24h || 400-800 mg divided q24h
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|-
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| [[gentamicin]] || 7.5 mg/kg divided q8h || 5 mg/kg divided q8h
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|-
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| [[linezolid]] || 30 mg/kg divided q8h (<12 years)<br/>20 mg/kg divided q12h (≥12 years) || 1200 mg divided q12h
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|-
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| liposomal [[amphotericin B]] || colspan=2 | 3-5 mg/kg divided q24h
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|-
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| [[meropenem]] || 120 mg/kg divided q8h || 6 g divided q8h
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|-
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| [[moxifloxacin]] || || 400 mg divided q24h
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|-
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| [[nafcillin]] || 200 mg/kg divided q6h || 12 g divided q4h
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|-
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| [[oxacillin]] || 200 mg/kg divided q6h || 12 g divided q4h
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|-
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| [[penicillin G]] || 300,000 U/kg divided q4-6h || 24 million U divided q4h
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|-
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| [[posaconazole]] || || 800 mg divided q6-12h
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|-
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| [[rifampin]] || 20 mg/kg divided q24h || 600 mg divided q24h
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|-
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| [[tobramycin]] || 7.5 mg/kg divided q8h || 5 mg/kg divided q8h
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|-
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| [[TMP-SMX]] || colspan=2 | 10-20 mg/kg divided q6-12h
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|-
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| [[vancomycin]] || 60 mg/kg divided q6h || 30-60 mg/kg divided q8-12h
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|-
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| [[voriconazole]] || 16 mg/kg divided q12h || 8 mg/kg divided q12h
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|}
   
 
[[Category:CNS infections]]
  
[[Category:CNS infections]]

Revision as of 20:13, 29 June 2020

Background

Microbiology

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 antibiotic 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

First- and second-line antimicrobials by organism

Organism First-line Second-line
Staphylococcus aureus (methicillin-susceptible) nafcillin or oxacillin vancomycin
Staphylococcus aureus (methicillin-resistant) vancomycin daptomycin, TMP-SMX, or linezolid
Streptococcus pneumoniae (penicillin MIC ≤0.06) penicillin G third-generation cephalosporin
Streptococcus pneumoniae (penicillin MIC ≥0.12) third-generation cephalosporin cefipime or meropenem
Streptococcus pneumoniae (ceftriaxone MIC ≥1) vancomycin plus a third-generation cephalosporin moxifloxacin
Pseudomonas aeruginosa cefipime, ceftazidime, or meropenem aztreonam or ciprofloxacin
Haemophilus influenzae (β-lactamase negative) ampicillin third-generation cephalosporin, cefepime, or a fluoroquinolone
Haemophilus influenzae (β-lactamase positive) third-generation cephalosporin cefepime, aztreonam, or a fluoroquinolone
ESBL Gram-negative bacillus meropenem cefepime or a fluoroquinolone
Acinetobacter baumannii meropenem colistin or polymixin B
Other Enterobacteriaceae third-generation cephalosporin meropenem, aztreonam, TMP-SMX, or ciprofloxacin
Candida species liposomal amphotericin B ± flucytosine fluconazole or voriconazole
Aspergillus species voriconazole liposomal amphotericin B or posaconazole

Recommended 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

  1. ^  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.

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