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)
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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
...ycin plus an anti-pseudomonal β-la...
...l adult patients with healthcare-asso...
For patients with healthcare-associated ve...
...nts with healthcare-associated ventriculitis and...
...of infection caused by methicillin-su...
...the patient cannot receive β-lactam agents, the...
...nt of infection caused by methicillin-resis...
...consideration for an alternative a...
...treatment of infection caused by coagulase-n...
If the staphylococcal isolate is susceptible to ri...
...commended as part of combination therapy for any...
...of patients with healthcare-assoc...
...methoprim-sulfamethoxazole ( S , L...
...treatment of infection caused by P. acnes...
...or treatment of infection caused by gram...
...r treatment of infection caused by gram-n...
...treatment of infection caused by Pseudomon...
...mmended alternative antimicrobial agents...
...infection caused by extended spectrum β-...
...treatment of infection caused by Ac...
...r strains demonstrating carbapenem resist...
...on of meropenem (each dose administered ov...
...treatment of infection caused by Candida s...
...t shows clinical improvement, therapy c...
...atment of infection caused by Aspergillus or E...
...traventricular Antimicrobia...
...entricular antimicrobial therapy should...
...timicrobial therapy is administere...
...s and intervals of intraventricular antimicrobial...
...ricular size, ( S , L)...
...ily output from the ventricular drain. ( S...
...l Duration of Antimicrobial Ther...
...d by a coagulase-negative Staphylococc...
...ed by a coagulase negative Staphylococcus...
...nfections caused by S. aureus or gram-ne...
...rts suggest treatment of infection caused by gram...
...th repeatedly positive CSF cultures on app...
...lete removal of an infected CSF shunt...
...l of an infected CSF drain is recommend...
...nfected intrathecal infusion pump is...
...val of infected hardware in patients w...
...with healthcare-associated ventriculiti...
...healthcare-associated ventriculitis and m...
In patients with no definitive clinical improv...
For external CSF drains not being used in...
...ents with infection caused by coagula...
In patients with infection caused by a coagulas...
...es are positive, antimicrobial treatment is recom...
...n patients with infection caused by S. aureus or...
...antimicrobial therapy is NOT recommended to veri...
...rophylactic antimicrobial administration is...
...dural prophylactic antimicrobial administ...
...onged antimicrobial prophylaxis for...
...of antimicrobial-impregnated CSF shunts and CS...
...th external ventricular drains, fixed in...
...tandardized protocol for insertion of CSF...
...rophylactic Antimicrobial...
...neurosurgical patients, perioperativ...
...atients with basilar skull fractures and a...
...atients with basilar skull fractures an...
...ents with basilar skull fractures and a...
...Recommended Antimicrobial Therapy in Patien...
...nded Dosages of Antimicrobial Agents in In...
Table 3. Recommended Dosages of Antimicrob...
