Ventriculitis and Meningitis Healthcare-Associated

Last updated April 8, 2022

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)
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Erythema and tenderness over the subcutaneous shunt tubing are suggestive of CSF shunt infection. ( S , M)
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Fever, in the absence of another clear source of infection, could be suggestive of CSF shunt infection. ( W , L)
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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)
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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)
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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)
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Demonstration of glomerulonephritis in a patient with a ventriculoatrial shunt is suggestive of CSF shunt infection. ( W , L)
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New or worsening altered mental status in patients with external ventricular drains is suggestive of infection. ( W , L)
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New fever and increased CSF white blood cell count in patients with external ventricular drains could be suggestive of infection. ( W , L)
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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)
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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)
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Intrathecal Infusion Pumps

New fever and drainage from the surgical site in patients with intrathecal infusion pumps are suggestive of wound infection. ( W , L)
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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)
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Normal CSF cell count, glucose and protein may not reliably exclude infection in patients with healthcare-associated ventriculitis and meningitis. ( W , M)
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A negative CSF Gram stain does not exclude the presence of infection, especially in patients who have received previous antimicrobial therapy ( S , M)
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Culture

CSF cultures are the most important test to establish the diagnosis of healthcare-associated ventriculitis and meningitis. ( S , H)
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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)
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If a CSF shunt or drain is removed in patients suspected of having infection, cultures of shunt and drain components are recommended. ( S , M)
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If a CSF shunt or drain is removed for indications other than infection, cultures of shunt or drain components are NOT recommended. ( S , M)
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Blood cultures are recommended in patients with suspected ventriculoatrial shunt infections. (S, H)
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Blood cultures may be considered in patients with ventriculoperitoneal and ventriculopleural shunts (W, L)
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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)
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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)
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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)
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Hypoglycorrhachia and elevated CSF protein concentrations are suggestive of the diagnosis of healthcare-associated ventriculitis or meningitis. ( W , L)
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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)
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CSF cultures with multiple organisms from a single sample may be contaminants in patients with no symptoms of infection or CSF pleocytosis. ( W , L)
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CSF cultures that grow Staphylococcus aureus or aerobic gram-negative bacilli are indicative of infection. ( S , M)
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CSF cultures that grow a fungal pathogen are indicative of infection. ( S , M)
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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)
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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)
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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)
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Detection of β–D-glucan and galactomannan in CSF may be useful in the diagnosis of fungal ventriculitis and meningitis. ( S , M)
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Imaging

Neuroimaging is recommended in patients with suspected healthcare-associated ventriculitis and meningitis. ( S , M)
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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)
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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)
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Treatment

...Treatment...

...Empiric Antim...

...an anti-pseudomonal β-lactam (such...

...ill adult patients with healthcare-as...

...ts with healthcare-associated ventri...

For patients with healthcare-associat...


...Specific Antimi...

...reatment of infection caused by methicillin-sus...

...the patient cannot receive β-lact...

...t of infection caused by methicillin-res...

...sideration for an alternative antimi...

For treatment of infection caused by coagulas...

...ylococcal isolate is susceptible to rifampin,...

...mmended as part of combination therapy for...

...atment of patients with healthcare-associate...

...aptomycin ( S , L)70...

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

For treatment of infection caused by...

...infection caused by gram-negative ba...

...treatment of infection caused by gram-negative b...

...ment of infection caused by Pseudomonas specie...

...lternative antimicrobial agents are...

...tment of infection caused by extended spectrum β...

...ent of infection caused by Acinetobacte...

...rains demonstrating carbapenem resistance, colisti...

...onged infusion of meropenem (each dose ad...

...r treatment of infection caused by C...

...atient shows clinical improvement,...

...ent of infection caused by Aspergi...


...Intraventricul...

...raventricular antimicrobial therapy sh...

...microbial therapy is administered via a v...

...ges and intervals of intraventricular antimicrob...

...ular size, ( S , L)705

...ily output from the ventricular drain. ( S , L)705...


...used by a coagulase-negative Staphyloc...

...ed by a coagulase negative Staphylococcu...

...sed by S. aureus or gram-negative...

...xperts suggest treatment of infecti...

...repeatedly positive CSF cultures on appropriate a...


...Catheter Remo...

...ete removal of an infected CSF shunt and rep...

...f an infected CSF drain is recommend...

...infected intrathecal infusion pump...

...nfected hardware in patients with deep brain stimu...


...Patient Monitoring...

...ents with healthcare-associated ve...

...tients with healthcare-associated ventric...

...ients with no definitive clinical...

...F drains not being used in the treatme...


...Shunt Reimpla...

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

...nts with infection caused by a coagulase-negative...

...peat cultures are positive, antimicrobi...

...th infection caused by S. aureus or gram...

...period off antimicrobial therapy is NOT recom...


...Prev...

...iprocedural prophylactic antimicrobial administ...

...edural prophylactic antimicrobial administration...

...rolonged antimicrobial prophylaxis for...

Use of antimicrobial-impregnated CSF shun...

...h external ventricular drains, fixed inte...

...andardized protocol for insertion of CSF...


...Prophyla...

...r neurosurgical patients, perioperati...

...patients with basilar skull fracture...

...with basilar skull fractures and a prolonge...

...with basilar skull fractures and a CSF lea...


...ecommended Antimicrobial Therapy in P...


.... Recommended Dosages of Antimicrobial Ag...


Table 3. Recommended Dosages of Ant...