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== |
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* 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]] 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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+ | |||
+ | === Duration of Antimicrobials === |
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+ | {| class="wikitable" |
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+ | !Organism |
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+ | !Scenario |
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+ | !Duration Without Shunt |
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+ | !Duration With Shunt |
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+ | !Timing of Shunt Reimplantation |
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+ | |- |
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+ | | rowspan="3" |[[Cutibacterium acnes]] or [[coagulase-negative staphylococci]] |
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+ | |no CSF abnormalities and negative cultures within 48 hours of externalization |
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+ | | colspan="2" |10 days |
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+ | |as soon as day 3 following externalization |
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+ | |- |
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+ | |CSF abnormalities but negative repeat cultures |
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+ | |10 to 14 days |
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+ | |14 days |
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+ | |after 7 days of antimicrobials |
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+ | |- |
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+ | |CSF abnormalities and positive repeat cultures |
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+ | |10 to 14 days |
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+ | |14 days |
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+ | |after 7 to 10 days of negative cultures |
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+ | |- |
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+ | |[[Staphylococcus aureus]] or [[Gram-negative bacilli]] |
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+ | | |
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+ | |14 days |
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+ | | |
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+ | |after 10 days of negative cultures |
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+ | |- |
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+ | |any |
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+ | |persistent positive CSF cultures |
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+ | | colspan="2" |14 days from last positive culture |
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+ | |7 to 10 days after last positive culture |
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+ | |} |
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+ | |||
+ | ===Antimicrobial Selection=== |
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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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+ | |||
+ | ===Antimicrobial 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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+ | |} |
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[[Category:CNS infections]] |
[[Category:CNS infections]] |
Latest revision as of 11:14, 27 May 2021
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
Duration of Antimicrobials
Organism | Scenario | Duration Without Shunt | Duration With Shunt | Timing of Shunt Reimplantation |
---|---|---|---|---|
Cutibacterium acnes or coagulase-negative staphylococci | no CSF abnormalities and negative cultures within 48 hours of externalization | 10 days | as soon as day 3 following externalization | |
CSF abnormalities but negative repeat cultures | 10 to 14 days | 14 days | after 7 days of antimicrobials | |
CSF abnormalities and positive repeat cultures | 10 to 14 days | 14 days | after 7 to 10 days of negative cultures | |
Staphylococcus aureus or Gram-negative bacilli | 14 days | after 10 days of negative cultures | ||
any | persistent positive CSF cultures | 14 days from last positive culture | 7 to 10 days after last positive culture |
Antimicrobial Selection
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.