Ventriculitis and Meningitis Healthcare-Associated

Publication Date: February 27, 2017

Diagnosis

Diagnosis

Typical Symptoms and Signs

Cerebrospinal Fluid (CSF) Shunts and Drains

New headache, nausea, lethargy and/or change in mental status are suggestive of CSF shunt infection. ( S , M)
705
Erythema and tenderness over the subcutaneous shunt tubing are suggestive of CSF shunt infection. ( S , M)
705
Fever, in the absence of another clear source of infection, could be suggestive of CSF shunt infection. ( W , L)
705
Symptoms and signs of peritonitis or abdominal tenderness in patients with ventriculoperitoneal shunts, in the absence of another clear etiology, are indicative of CSF shunt infection. ( S , M)
705
Symptoms and signs of pleuritis in patients with ventriculopleural shunts, in the absence of another clear etiology, are indicative of CSF shunt infection. ( S , M)
705
Demonstration of bacteremia in a patient with a ventriculoatrial shunt, in the absence of another clear source of bacteremia, is evidence of CSF shunt infection. ( S , M)
705
Demonstration of glomerulonephritis in a patient with a ventriculoatrial shunt is suggestive of CSF shunt infection. ( W , L)
705
New or worsening altered mental status in patients with external ventricular drains is suggestive of infection. ( W , L)
705
New fever and increased CSF white blood cell count in patients with external ventricular drains could be suggestive of infection. ( W , L)
705

Neurosurgery or Head Trauma

New headache, fever, evidence of meningeal irritation, seizures and/or worsening mental status are suggestive of ventriculitis or meningitis in the setting of recent trauma or neurosurgery. ( S , M)
705
Fever, in the absence of another clear source of infection, is suggestive of central nervous system (CNS) infection in the setting of recent head trauma or neurosurgery. ( W , L)
705

Intrathecal Infusion Pumps

New fever and drainage from the surgical site in patients with intrathecal infusion pumps are suggestive of wound infection. ( W , L)
705

Typical Cerebrospinal Fluid Findings

Cell Count, Glucose and Protein

Abnormalities of CSF cell count, glucose and/or protein may not be reliable indicators for the presence of infection in patients with healthcare-associated ventriculitis and meningitis. ( W , M)
705
Normal CSF cell count, glucose and protein may not reliably exclude infection in patients with healthcare-associated ventriculitis and meningitis. ( W , M)
705
A negative CSF Gram stain does not exclude the presence of infection, especially in patients who have received previous antimicrobial therapy ( S , M)
705

Culture

CSF cultures are the most important test to establish the diagnosis of healthcare-associated ventriculitis and meningitis. ( S , H)
705
If initial CSF cultures are negative in patients with CSF shunts or drains with suspected infection, it is recommended that cultures should be held for at least 10 days in an attempt to identify organisms such as Propionibacterium acnes. ( S , H)
705
If a CSF shunt or drain is removed in patients suspected of having infection, cultures of shunt and drain components are recommended. ( S , M)
705
If a CSF shunt or drain is removed for indications other than infection, cultures of shunt or drain components are NOT recommended. ( S , M)
705
Blood cultures are recommended in patients with suspected ventriculoatrial shunt infections. (S, H)
705
Blood cultures may be considered in patients with ventriculoperitoneal and ventriculopleural shunts (W, L)
705
Single or multiple positive CSF cultures in patients with CSF pleocytosis and/or hypoglycorrhachia, or an increasing cell count, and clinical symptoms suspicious for ventriculitis or meningitis, is indicative of CSF drain infection. (S, H)
705
CSF and blood cultures in selected patients should be obtained before the administration of antimicrobial therapy. A negative CSF culture in the setting of previous antimicrobial therapy does not exclude healthcare-associated ventriculitis and meningitis (S, M)
705

Neurosurgery or Head Trauma

CSF pleocytosis with a positive culture and symptoms of infection are indicative of a diagnosis of healthcare-associated ventriculitis or meningitis (S, H)
705
Hypoglycorrhachia and elevated CSF protein concentrations are suggestive of the diagnosis of healthcare-associated ventriculitis or meningitis. ( W , L)
705
Growth of an organism which is commonly considered a contaminant (e.g., coagulase-negative Staphylococcus) in enrichment broth only or on just one of multiple cultures, in a patient with normal CSF and no fever, is not indicative of healthcare-associated ventriculitis or meningitis. ( S , L)
705
CSF cultures with multiple organisms from a single sample may be contaminants in patients with no symptoms of infection or CSF pleocytosis. ( W , L)
705
CSF cultures that grow Staphylococcus aureus or aerobic gram-negative bacilli are indicative of infection. ( S , M)
705
CSF cultures that grow a fungal pathogen are indicative of infection. ( S , M)
705

Specific CSF Tests to Confirm the Diagnosis

An elevated CSF lactate or an elevated CSF procalcitonin, or the combination of both, may be useful in the diagnosis of healthcare-associated bacterial ventriculitis and meningitis. ( W , M)
705
An elevated serum procalcitonin may be useful in differentiating between CSF abnormalities due to surgery or intracranial hemorrhage from those due to bacterial infection. ( W , L)
705
Nucleic acid amplification tests, such as polymerase chain reaction (PCR), on CSF may both increase the ability to identify a pathogen and decrease the time to making a specific diagnosis. ( W , L)
705
Detection of β–D-glucan and galactomannan in CSF may be useful in the diagnosis of fungal ventriculitis and meningitis. ( S , M)
705

Imaging

Neuroimaging is recommended in patients with suspected healthcare-associated ventriculitis and meningitis. ( S , M)
705
Magnetic resonance imaging (MRI) with gadolinium-enhancement and diffusion-weighted imaging is recommended for detecting abnormalities in patients with healthcare-associated ventriculitis and meningitis. ( S , M)
705
In patients with infected ventriculoperitoneal shunts and abdominal symptoms (e.g., pain or tenderness), an ultrasound or computed tomography (CT) of the abdomen is recommended to detect CSF loculations at the shunt terminus. ( S , M)
705

Treatment

...reatment...

...iric Antimicrob...

Vancomycin plus an anti-pseudomonal β-l...

...usly ill adult patients with healthcare-associate...

...with healthcare-associated ventriculitis a...

...with healthcare-associated ventriculitis...


...cific Antimicrobials

...r treatment of infection caused by methici...

...cannot receive β-lactam agents, the patient c...

...infection caused by methicillin-re...

...ion for an alternative antimicrobial agen...

...infection caused by coagulase-negative st...

...staphylococcal isolate is suscepti...

...in is recommended as part of combination therapy...

...reatment of patients with healthcare-asso...

...ptomycin ( S , L)705

...thoprim-sulfamethoxazole ( S , L)705...

...tment of infection caused by P. acnes, pen...

...or treatment of infection caused by gram-ne...

...atment of infection caused by gram-...

For treatment of infection caused by P...

...ternative antimicrobial agents are aztreonam...

...tment of infection caused by extended spe...

...eatment of infection caused by Acinetobact...

...strains demonstrating carbapenem resist...

...nged infusion of meropenem (each dose...

...of infection caused by Candida species, based on...

...ce the patient shows clinical improvement, therapy...

...reatment of infection caused by Aspergillus or Ex...


...ventricular Antimicrobial Ther...

...antimicrobial therapy should be co...

...n antimicrobial therapy is adminis...

...d intervals of intraventricular antimicrobial...

...entricular size, ( S , L)...

...t from the ventricular drain. ( S , L)70...


...ion of Antimicrobial Therapy...

...caused by a coagulase-negative Staphyl...

...s caused by a coagulase negative Staphylococcus or...

...ions caused by S. aureus or gram-negative baci...

...ome experts suggest treatment of infection caused...

...ts with repeatedly positive CSF cultures on appr...


...theter Remov...

...plete removal of an infected CSF shunt...

...an infected CSF drain is recommended. (...

...emoval of an infected intrathecal infusi...

...l of infected hardware in patients with deep b...


...ent Monitoring...

...althcare-associated ventriculitis and meningitis...

...healthcare-associated ventriculitis and m...

...with no definitive clinical improv...

...xternal CSF drains not being used in the treatme...


...hunt Reimplantion

...with infection caused by coagulase-negative stap...

...ents with infection caused by a coagulase...

...epeat cultures are positive, antimicrobial...

...n patients with infection caused by S. aure...

A period off antimicrobial therapy is NOT re...


...vention

...al prophylactic antimicrobial administration is r...

...l prophylactic antimicrobial administ...

...crobial prophylaxis for the duration of the ext...

...icrobial-impregnated CSF shunts and...

...n patients with external ventricular drain...

...se of a standardized protocol for inse...


...ctic Antimicrobial Therapy

...eurosurgical patients, perioperative antimicrob...

...ts with basilar skull fractures and a C...

...h basilar skull fractures and a prolonged C...

...nts with basilar skull fractures and a CSF le...


...able 1. Recommended Antimicrobial Therapy...


...mmended Dosages of Antimicrobial Agents in...


...3. Recommended Dosages of Antimicro...