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
...mpiric Antimicrobials...
...cin plus an anti-pseudomonal β-lactam (such as c...
...ly ill adult patients with healthc...
...ts with healthcare-associated ventriculitis and...
...ts with healthcare-associated ventriculiti...
...of infection caused by methicillin-susceptible...
...atient cannot receive β-lactam age...
...treatment of infection caused by methicill...
...ation for an alternative antimicrobial agent if...
...nt of infection caused by coagulase-negati...
...occal isolate is susceptible to rifampin, this...
...ampin is recommended as part of combination therap...
...eatment of patients with healthcare-associa...
...rimethoprim-sulfamethoxazole ( S , L)705...
...of infection caused by P. acnes, penicillin G is r...
...r treatment of infection caused by gram-negative b...
...f infection caused by gram-negative bacilli...
...reatment of infection caused by Pseu...
...ommended alternative antimicrobial agents are...
...ent of infection caused by extended spectru...
...f infection caused by Acinetobacter spec...
...onstrating carbapenem resistance, colistimethat...
...longed infusion of meropenem (each dose adminis...
...t of infection caused by Candida specie...
...ce the patient shows clinical improvement, the...
...treatment of infection caused by Aspergillu...
...ventricular Antimicrobial The...
...tricular antimicrobial therapy should be co...
...imicrobial therapy is administered via...
Dosages and intervals of intraventricular antimic...
...icular size, ( S , L)705...
...aily output from the ventricular drain. ( S...
...ration of Antimicrobial Ther...
...used by a coagulase-negative Staphyloc...
...caused by a coagulase negative Staphylococcus o...
...ons caused by S. aureus or gram-negative...
...e experts suggest treatment of infection...
...atients with repeatedly positive CSF cult...
...plete removal of an infected CSF shun...
...n infected CSF drain is recommende...
...of an infected intrathecal infusion...
...cted hardware in patients with deep...
...with healthcare-associated ventriculiti...
...ients with healthcare-associated ventricul...
...th no definitive clinical improvement, addit...
...or external CSF drains not being used in the trea...
...s with infection caused by coagulase-negative sta...
...n patients with infection caused by...
...res are positive, antimicrobial treatment is reco...
...nts with infection caused by S. aureu...
...period off antimicrobial therapy is NOT r...
...prophylactic antimicrobial administration is reco...
...dural prophylactic antimicrobial administr...
...microbial prophylaxis for the duration of th...
...ntimicrobial-impregnated CSF shunts an...
...ith external ventricular drains, fixed interval e...
...f a standardized protocol for insertion of CS...
...c Antimicrobial Therapy...
...neurosurgical patients, perioperativ...
...with basilar skull fractures and a C...
...atients with basilar skull fractures and a prolon...
...patients with basilar skull fractures a...
...mmended Antimicrobial Therapy in P...
...Recommended Dosages of Antimicrobial Agents in In...
...3. Recommended Dosages of Antimicrobial Agents Ad...
