Healthcare-associated Meningitis Research Articles

Clinical characteristics and antimicrobial therapy of healthcare-associated carbapenem-non-susceptible gram-negative bacterial meningitis: a 16-year retrospective cohort study

ObjectiveHealthcare-associated Gram-negative bacterial meningitis is a substantial clinical issue with poor outcomes, especially for neurosurgical patients. Here, we aimed to study the characteristics and treatment options of patients with healthcare-associated carbapenem-non-susceptible (Carba-NS) Gram-negative bacterial meningitis.MethodsThis observational cohort study was conducted at a teaching hospital from 2004 to 2019. The clinical characteristics of patients with meningitis with Carba-NS and carbapenem-susceptible (Carba-S) bacilli were compared, and the antimicrobial chemotherapy regimens and outcomes for Carba-NS Gram-negative bacterial meningitis were analyzed.ResultsA total of 505 patients were included, of whom 83.8% were post-neurosurgical patients. The most common isolates were Acinetobacter spp. and Klebsiella spp., which had meropenem-resistance rates of 50.6% and 42.5%, respectively, and showed a markedly growing carbapenem-resistance trend. Kaplan–Meier curve analysis revealed that Carba-NS Gram-negative bacilli were associated with a significantly higher in-hospital mortality rate (18.8%, 35/186) compared to the Carba-S group (7.4%, 9/122; P = 0.001). For Carba-NS Enterobacterales meningitis, aminoglycoside-based and trimethoprim-sulfamethoxazole-based regimens yielded significantly higher clinical efficacy rates than non-aminoglycoside-based and non-trimethoprim-sulfamethoxazole-based regimens (69.0% vs. 38.7%, P = 0.019 and 81.8% vs. 46.9%, P = 0.036, respectively). For Carba-NS A. baumannii complex meningitis, tetracycline-based (including doxycycline, minocycline, or tigecycline) therapy achieved a significantly higher clinical efficacy rate (62.9%, 22/35) than the non-tetracycline-based therapy group (40.4%, 19/47; P = 0.044).ConclusionsOur findings revealed that Carba-NS Gram-negative bacilli are associated with higher in-hospital mortality in patients with healthcare-associated meningitis. The combination therapies involving particular old antibiotics may improve patients’ outcome.Trial registrationThis study was registered on the Chinese Clinical Trial Register under ChiCTR2000036572 (08/2020).

Clinical characteristics and prognosis of Klebsiella pneumoniae meningitis in adults

BackgroundKlebsiella pneumoniae is a causative agent of bacterial meningitis in adults. However, there is little information regarding this infection. Therefore, this study comprehensively analyzed the clinical characteristics and prognosis of Klebsiella pneumoniae meningitis (KPM) patients. MethodsThe clinical data of adult hospitalized patients with KPM were retrospectively collected from January 2015 to December 2022. The clinical characteristics and antibiotic resistance of KPM were evaluated. Meanwhile, a set of logistic regression models was constructed to identify prognostic factors for death. These prognostic factors were subsequently combined to develop a nomogram for predicting the risk of in-hospital mortality in individual patients. Finally, the receiver operating characteristic curve and calibrate plot were utilized to verify the performance of the nomogram. ResultsThis study included 80 adult patients with KPM, 58 (72.5%) of whom were males. The mortality rate was 45%. Among them, 74 (92.5%) were diagnosed with healthcare-associated meningitis. Thirty-seven carbapenem-resistant Klebsiella pneumoniae (CRKP) strains were susceptible to tigecycline, polymyxin, and ceftazidime/avibactam. CRKP (OR = 9.825, 95%CI = 2.757–35.011, P < 0.001), length of stay (OR = 0.953, 95%CI = 0.921–0.986, P = 0.005), and C-reactive protein-to-prealbumin ratio (CRP/PA, OR = 3.053, 95%CI = 1.329–7.016, P = 0.009) were identified as predictive factors for mortality using multivariate logistic regression. Finally, a nomogram for death prediction was established. The area under the curve of this nomogram was 0.900 (95% CI = 0.828–0.971). ConclusionsKPM is a fatal disease associated with high incidence of healthcare-associated infections and carbapenem resistance. Moreover, CRKP, length of stay, and CRP/PA were found to be independent predictors of mortality.

Empirical cefepime+vancomycin versus ceftazidime+vancomycin versus meropenem+vancomycin in the treatment of healthcare-associated meningitis: results of the multicenter Ephesus study

BackgroundHerein, we analyzed the efficacy of main antibiotic therapy regimens in the treatment of healthcare-associated meningitis (HCAM).Materials/methodsThis retrospective cohort study was conducted in 18 tertiary-care academic hospitals Turkey, India, Egypt and Romania. We extracted data and outcomes of all patients with post-neurosurgical meningitis cases fulfilling the study inclusion criteria and treated with empirical therapy between December 2006-September 2018.ResultsTwenty patients in the cefepime + vancomycin-(CV) group, 31 patients in the ceftazidime + vancomycin-(CFV) group, and 119 patients in the meropenem + vancomycin-(MV) group met the inclusion criteria. The MV subgroup had a significantly higher mean Glasgow Coma Score, a higher rate of admission to the intensive care unit within the previous month, and a higher rate of antibiot herapy within the previous month before the meningitis episode (p < 0.05). Microbiological success on Day 3–5, end of treatment (EOT) clinical success (80% vs. 54.8%% vs 57.9%), and overall success (EOT success followed by one-month survival without relapse or reinfection 65% vs. 51.6% vs. 45.3%), EOT all cause mortality (ACM) and day 30 ACM (15% vs. 22.6% vs. 26%) did not differ significantly (p > 0.05) among the three cohorts. No regimen was effective against carbapenem-resistant bacteria, and vancomycin resulted in an EOT clinical success rate of 60.6% in the methicillin-resistant staphylococci or ampicillin-resistant enterococci subgroup (n = 34).ConclusionsOur study showed no significant difference in terms of clinical success and mortality among the three treatment options. All regimens were ineffective against carbapenem-resistant bacteria. Vancomycin was unsuccessful in approximately 40% of cases involving methicillin-resistant staphylococci or ampicillin-resistant enterococci.

Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Causing Nosocomial Meningitis in the Neurological Intensive Care Unit.

Acinetobacter baumannii is one of the significant healthcare-associated meningitis agents characterized by multidrug resistance and a high mortality risk. Thirty-seven A. baumannii strains were isolated from thirty-seven patients of Moscow neuro-ICU with meningitis in 2013-2020. The death rate was 37.8%. Strain susceptibility to antimicrobials was determined on the Vitek-2 instrument. Whole-genome sequencing was conducted using Illumina technology; the sequence types (ST), capsular types (KL), lipooligosaccharide outer core locus (OCL), antimicrobial resistance genes, and virulence genes were identified. The prevalent ST was ST2, belonging to the international clone IC2, and rarer, ST1, ST19, ST45, ST78, ST106, and ST400, with prevalence of KL9 and OCL1. Twenty-nine strains belonged to multidrug-resistant (MDR) and eight extensively drug-resistant (XDR) categories. Genes conferring resistance to beta-lactams (blaPER, blaGES, blaADC, blaCARB, blaCTX-M, blaTEM, and blaOXA-types), aminoglycosides (aac, aad, ant, aph, and arm), tetracyclines (tet), macrolides (msr and mph), phenicols (cml, cat, and flo), sulfonamides (dfr and sul), rifampin (arr), and antiseptics (qac) were identified. Virulence genes of nine groups (Adherence, Biofilm formation, Enzymes, Immune evasion, Iron uptake, Regulation, Serum resistance, Stress adaptation, and Antiphagocytosis) were detected. The study highlights the heterogeneity in genetic clones, antimicrobial resistance, and virulence genes variability among the agents of A. baumannii meningitis, with the prevalence of the dominant international clone IC2.

Off-Label Use of Ceftolozane/Tazobactam for the Successful Treatment of Healthcare-Associated Meningitis Caused by Extensively Drug-Resistant Pseudomonas aeruginosa in a Polytraumatized Patient—A Case Report

Background: Hospital-acquired infections with extensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) have become a worrisome concern because of unfavorable outcomes and limited antimicrobial treatment options. Studies with new antimicrobial substances against XDR-PA show very promising results in different infection types, but the data for central nervous system (CNS) infections are scarce. Case presentation: Here, we report the case of a young patient with healthcare-associated meningitis caused by XDR-PA following severe craniocerebral injury. An off-label use of high-dose ceftolozane/tazobactam (C/T) monotherapy was administered for 10 days in parallel with source-controlling measures. Clinical and microbial recovery could be accomplished promptly. Conclusion: In patients with hospital-acquired CNS infections due to XDR-PA, C/T might be a new, safe and effective alternative with fewer adverse effects compared to older polymyxin- or aminoglycoside-based regimens.

Etiology and Outcomes of Healthcare-Associated Meningitis and Ventriculitis-A Single Center Cohort Study.

Healthcare associated meningitis and ventriculitis (HCAMV) are serious complications of neurosurgical procedures. We conducted a retrospective cohort study of patients with HCAMV treated at the University Hospital for Infectious Diseases Zagreb during the 2013–2019 period. A total of 144 patients with 151 episodes of HCAMV were included. The most common indications for neurosurgical procedures were brain tumor, hemorrhage and hydrocephalus. Etiology was identified in 90 (59.6%) episodes (either positive CSF culture or positive PCR), and in other 61 (40.39%) the diagnosis of HCAMV was made based on clinical and CSF parameters, without microbiologic confirmation. Carbapenem-resistant Acinetobacter baumannii was the most common pathogen (15.89%), followed by Staphylococcus aureus (13.91%), Pseudomonas aeruginosa (13.25%) and Coagulase negative staphylococci (7.95%). Overall, 24 (16.3%) patients died, and the majority had adverse outcomes, persistent vegetative state (8, 5.56%) and severe disability (31, 21.53%). The worst clinical outcomes were observed in A. baumannii infections. High rate of complications, the need for external ventricular drainage (re)placement often complicated with nosocomial infections and prolonged stay in intensive care units were observed. Clinicians should be aware of local microbial epidemiology on guiding proper empirical antimicrobial treatment in patients with HCAMV.

How we deal with Staphylococcus aureus (MSSA, MRSA) central nervous system infections.

Among central nervous system (CNS) infections (e.g., meningitis, brain abscess, ventriculitis, transverse myelitis), those caused by Staphylococcus aureus (SA) are particularly challenging both in management and treatment, with poor clinical outcomes and long hospital stay. It has been estimated that SA is responsible for around 1%-7% of meningitis (up to 19% in healthcare-associated meningitis). Recent neurosurgical procedures and immunocompromisation are major risk factors for SA CNS infections. Hand hygiene, surveillance nasal swabs and perioperative prophylaxis are crucial points for effective SA infections prevention. In case of SA-CNS infections, pending microbiological results, anti-methicillin-resistant SA (MRSA) antibiotic, with good CNS penetration, should be included, with prompt de-escalation as soon as MRSA is ruled out. Consultation with an expert in antimicrobial therapy is recommended as well as prompt source control when feasible. In this narrative review, we reviewed current literature to provide practical suggestions on diagnosis, prevention, management, and treatment of SA CNS infections.

Epidemiology and clinical characteristics of Klebsiella spp. meningitis in France

ObjectivesTo describe the epidemiology of Klebsiella spp. meningitis in France with respect to clinical and bacteriological data. MethodsWe performed a four-year multicenter, retrospective, observational study. The primary objective was to provide a clinical description of patients with Klebsiella spp. meningitis. Secondary objectives were to compare community-acquired meningitis and healthcare-associated meningitis and to analyze factors associated with mortality. ResultsWe enrolled 131 patients with Klebsiella spp. meningitis. Eighty-two (62.6%) infections were reported following neurosurgery. Twenty-eight strains (21.4%) were resistant to third-generation cephalosporins (3GC). The median [IQR] cellularity was 980/mm3 [116–5550], the median protein level was 5.67 [1.62–9] g/L and the median CSF glucose level was 2.5 [0–3.4] mmol/L. The in-hospital mortality rate was 23.6%. Community-acquired meningitis isolates were more frequently susceptible to 3GC than isolates from healthcare-associated meningitis (89.2% versus 72%; P=0.04). Comorbidities reported for patients with community-acquired meningitis were mainly diabetes mellitus and liver cirrhosis. In multivariate analysis, focal neurological disorder at the time of diagnosis was the only factor associated with in-hospital mortality (P=0.01). ConclusionsPurulent meningitis caused by Klebsiella spp. needs to be considered in patients with community-acquired meningitis and preexisting conditions, as well as in case of meningitis following neurosurgical procedures.

Antimicrobial use in central nervous system infections.

Central nervous system (CNS) infections are associated with high rates of morbidity and mortality. The purpose of this review is to summarize current antimicrobial therapies, as well as, updates in the management of community-acquired meningitis and healthcare-associated meningitis and ventriculitis. Due to the increasing rates of multidrug resistant and extensively-drug resistant organisms, available antimicrobials are limited. Novel treatment options include newer systemic antimicrobials and antimicrobials that have previously limited data in the management of CNS infections. Although limited by retrospective data, intrathecal (IT) and intraventricular (IVT) routes of administration offer the opportunity for antimicrobials that conventionally have minimal cerebrospinal fluid (CSF) penetration to achieve high CSF concentrations while minimizing systemic exposure. Updates in the use of systemic, IT, and IVT antimicrobials offer promise as therapeutic options for CNS infections. Additional pharmacokinetic and prospective data are needed to confirm these findings.

Impact of an educational program on reducing health care–associated meningitis or ventriculitis in the neurosurgical intensive care unit

Health care-associated meningitis or ventriculitis (HCAMV) is a serious complication in different neurosurgical procedures and is associated with significant morbidity and mortality. We aimed to investigate whether an educational intervention program could reduce the HCAMV incidence in patients undergoing postsurgery external ventricular drainage and wound management. We enrolled 2,904 patients from the neurosurgery intensive care unit between January 1, 2016 and December 31, 2018. The medical staff undertook an educational program developed by a multidisciplinary team on correct external ventricular drainage insertion and maintenance. The program included a 9-page self-learning module on the HCAMV risk factors and operational improvements. Each participant completed a pre- and posttest on their HCAMV knowledge. We found that 38 of 693 (5.48%) patients presented with infection in the preintervention 9-month period. In the 27-month postintervention period, the proportion of HCAMV incidence dropped by 52.19% (P < .0001) to 58 of 2,211 (2.62%) patients. Educational intervention aimed at the neurosurgery intensive care unit staff could significantly reduce the HCAMV rate, leading to a significant decline in the cost, morbidity, and mortality caused by neurosurgical procedures.

1302. HIV Testing in Adults Presenting with Central Nervous System (CNS) Infections

BackgroundThe Centers for Disease Control and Prevention recommends that all patients be tested for HIV while in a healthcare setting. HIV testing is especially important in patients with a central nervous system (CNS) infection because it impacts the differential diagnosis. In this study, we determined the rate of HIV testing in patients who presented with a CNS infection.MethodsWe performed a multicenter retrospective study of 1,312 patients over the age of 17 years with community or healthcare-acquired meningitis, aseptic meningitis or encephalitis admitted to 18 hospitals in New Orleans, LA and Houston, TX from July 1, 1998 through December 31, 2017. Prospective patients were identified using ICD 9 coding, physical examination findings, and cerebrospinal fluid analysis. The electronic medical records for these patients were reviewed for HIV testing and diagnosis. Aseptic meningitis cases were also reviewed for HIV RNA PCR testing. 100 patients with a known HIV diagnosis were excluded (2 aseptic meningitis, 82 encephalitis, and 16 community-acquired meningitis).ResultsOut of 1,312 patients presenting with a confirmed CNS infection, 664 (50.6%) had an HIV test done. A total of 81 patients (12.2%) were newly diagnosed with HIV during admission. Patients who underwent HIV testing were more likely to be non-caucasian, have no underlying comorbidities, lower Glasgow coma scale, and more seizures on presentation (P < 0.05). HIV testing also varied by type of CNS infection: community-acquired meningitis (98/142, 69.0%); encephalitis (180/261, 69.0%), aseptic meningitis (300/643, 46.6%), and healthcare-associated meningitis (86/289, 29.7%). In only 35 out of 547 patients (6.4%) presenting with acute aseptic meningitis was an HIV RNA PCR test ordered; 26 out of the 35 (74%) HIV RNA PCRs were positive with 9 patients being diagnosed with acute HIV seroconversion syndrome.ConclusionHIV testing is done in only one-half of patients with CNS infections with only a minority of patients presenting with acute aseptic meningitis being evaluated for acute HIV seroconversion syndrome. Clinicians should order an HIV test on all patients with CNS infections and consider testing for HIV RNA PCR in patients presenting with acute aseptic meningitis especially in those where the etiologic diagnosis remains unknown.Disclosures All authors: No reported disclosures.

1400. Impact of a Multiplex Polymerase Chain Reaction Meningitis/Encephalitis Panel and Antimicrobial Stewardship Bundle on Antimicrobial Use in Patients with Suspected Meningitis or Encephalitis

BackgroundOptimal treatment of meningitis relies on prompt diagnostic evaluation and initiation of appropriate antimicrobials. The meningitis/encephalitis panel (MEP) is a multiplex rapid polymerase chain reaction, with the ability to detect 14 community-acquired pathogens in 1 hour. The purpose of this study was to evaluate impact of the MEP on de-escalation of antimicrobials in adult inpatients with suspected meningitis at a large community teaching hospital.MethodsThis single-center retrospective quasi-experimental pre/post study included adults admitted for ≥48 hours and initiated on antimicrobial therapy for suspected meningitis. Those with healthcare-associated meningitis, immunosuppression, initiation of antimicrobials >8 hours prior to lumbar puncture (LP), and use of antimicrobials for another indication were excluded. The pre-group included patients admitted prior to MEP introduction. The post-group included patients with the MEP performed. An antimicrobial stewardship bundle consisting of a meningitis order set, provider education, and use of a real-time meningitis alert in clinical decision support software was also implemented in the post-group. The primary outcome was percentage of patients experiencing antimicrobial de-escalation ≤48 hours after LP. Secondary outcomes included time to de-escalation, total duration of antimicrobial therapy (DOT), and hospital length of stay (LOS).ResultsA total of 45 patients were included in the study (23 pre-group and 22 post-group). Baseline characteristics were similar between groups. The percentage of patients experiencing de-escalation of antimicrobials ≤ 48 hours after LP increased by 44% in the post-group (82% vs. 38%, P = 0.005). The overall median time to de-escalation of antimicrobials decreased by 35 hours [11.1 (IQR 5.6, 17.6) vs. 46.1 (IQR 18.4, 66.5); P = 0.002] and the median time to de-escalation after LP decreased by 38 hours [13.6 (IQR 8.3, 20.3) vs. 51.6 (IQR 44.2, 69.8); P < 0.001]. No statistically significant difference in hospital LOS or total DOT was seen.ConclusionImplementation of the MEP and antimicrobial stewardship bundle increased the percentage of patients de-escalated in 48 hours and decreased the time to de-escalation. However, this did not impact the total DOT or hospital LOS.Disclosures All authors: No reported disclosures.

Healthcare-Associated Infections in the Neurocritical Care Unit.

This article summarizes updated data and knowledge on healthcare-associated infections in the neurocritical care unit, with a focus on central nervous system infections and systemic infectious complications in patients with acute brain disease. It also reviews the concept of brain injury-induced immune modulation, an underlying mechanism to explain why the neuro-ICU population is particularly susceptible to infections. Healthcare-associated infections in the neuro-ICU are common: up to 40% of meningitides in the developed world are now healthcare-associated. The number of gram-negative infections is rising. New diagnostic approaches attempt to aid in the diagnosis of healthcare-associated meningitis and ventriculitis. Healthcare-associated infections in the neurocritical care unit remain a challenge for diagnosis, treatment, and prevention. Gaining a better understanding of at-risk patients and development of preventative strategies will be the goal for future investigation.

A Review of Safety and Effectiveness of Intravenous and Intraventricular Tigecycline in Healthcare-Associated Acinetobacter baumannii Meningitis and Ventriculitis

To review the clinical data on the safety and effectiveness of intravenous (IV) and intraventricular (IVT) tigecycline in healthcare-associated Acinetobacter baumannii meningitis and ventriculitis. A literature search was performed in PubMed (from 2005 to December 2018). The bibliographies of the retrieved articles were searched for additional relevant studies. Articles were included if they described the use of tigecycline (IV and/or IVT) in patients with healthcare-associated A. baumannii meningitis or ventriculitis. Clinical studies as well as case series and case reports were included, while animal and in vitro studies were excluded. The use of IV and/or IVT tigecycline was described in 39 patients infected with healthcare-associated A. baumannii meningitis or ventriculitis in 14 reports; 12 were case reports, one was case series, and one was retrospective multicenter study evaluating 23 carbapenem-resistant A. baumannii healthcare-associated meningitis cases treated with IV tigecycline including regimens. Using tigecycline was successful in most cases. Treatment failed in two patients and two patients died. Despite the limited studies, IV and IVT tigecycline has been used successfully and safely for the treatment of healthcare-associated A. baumannii meningitis and ventriculitis. However, large randomized controlled trials are necessary to clearly evaluate the safety and effectiveness of IV and IVT tigecycline in healthcare-associated A. baumannii meningitis and ventriculitis.

Daptomycin Plasma and CSF Levels in Patients with Healthcare-Associated Meningitis.

There are currently few data concerning the cerebrospinal fluid (CSF) penetration of daptomycin in patients with healthcare-associated meningitis. This study aims (1) to better characterize the pharmacokinetics of daptomycin in humans during a 7-day intravenous (IV) therapy course, and (2) to study the penetration of daptomycin in the CSF after IV infusion at the dose of 10mg/kg. In this prospective observational study, we enrolled nine patients with an implanted external ventricular drainage and a diagnosis of a healthcare-associated meningitis. Daptomycin was administered at 10mg/kg for a maximum of 7days. The pharmacokinetic of daptomycin was studied using a two-compartment population/pharmacokinetic (POP/PK) model and by means of a nonlinear mixed effects modeling approach. A large inter-individual variability in plasma area under the curve (Range: 574.7-1366.3hmg/L), paralleled by high-peak plasma concentration (Cmax) (all values > 60mg/L), was noted. The inter-individual variability of CSF-AUC although significant (range: 1.17-6.81hmg/L) was narrower than previously reported and with a late occurrence of CSF-Cmax (range: 6.04-9.54h). The terminal half-life between plasma and CSF was similar. tmax values in CSF did not show a high inter-individual variability, and the fluctuations of predicted CSF concentrations were minimal. The mean value for daptomycin penetration obtained from our model was 0.45%. Our POP/PK model was able to describe the pharmacokinetics of daptomycin in both plasma and CSF, showing that daptomycin (up to 7days at 10mg/kg) has minimal penetration into central nervous system. Furthermore, the observed variability of AUC, tmax and predicted concentration in CSF was lower than what previously reported in the literature. Based on the present findings, it is unlikely that daptomycin could reach CSF concentrations high enough to have clinical efficacy; this should be tested in future studies.

Coagulase-negative staphylococci are associated to the mild inflammatory pattern of healthcare-associated meningitis: a retrospective study.

The epidemiology of healthcare-associated meningitis (HAM) is dominated by commensal bacteria from the skin, as coagulase-negative staphylococci (CoNS). We hypothesized that the pauci-symptomatic and mild inflammatory patterns of HAM are related to the low pathogenic state of CoNS. Our aim was to describe clinical and biological features of CoNS HAM, compared to other HAM. All consecutive patients with HAM admitted in our hospital were retrospectively included from 2007 to 2014. HAM due to CoNS were compared to HAM caused by other bacteria (controls) for clinical and laboratory patterns. Seventy-one cases of HAM were included, comprising 18 CoNS and 53 controls. Patients were not different in terms of baseline characteristics. CoNS HAM occurred later after the last surgery than controls (17 vs. 12 days, p = 0.029) and had higher Glasgow Coma Scale (GCS) score (14 vs. 13, p = 0.038). Cerebrospinal fluid (CSF) analysis revealed a lower pleocytosis (25 vs. 1340/mm3, p < 0.001), a higher glucose level (3.75 vs. 0.8mmol/L, p < 0.001), and a lower protein level (744 vs. 1751mg/L, p < 0.001) in the CoNS group than in the control group, respectively. HAM due to CoNS was significantly less symptomatic and less inflammatory than HAM due to other bacteria.

Менингиты и вентрикулиты, связанные с оказанием медицинской помощи: диагностика, лечение и профилактика

Healthcare-associated meningitis and ventriculitis are a common problem of modern public health, which are characterized by diverse etiological spectrum of multidrug resistant microorganisms, presented by difficulties for early diagnosis and adequate treatment, and are often accompanied by a high risk of secondary complications and an unfavorable outcome. This article presents the clinical guidelines of the American Society of Infectious Diseases (IDSA) for the diagnosis and treatment of healthcare-associated meningitis and ventriculitis published in 2017 and may be useful for professionals working with this category of patients.

Diagnostic accuracy of CSF cell index and corrected CSF white blood cell count in healthcare-associated ventriculitis and meningitis after intracranial hemorrhage

Abstract Background The diagnosis of healthcare-associated meningitis and ventriculitis (HCAMV) in patients with intracranial hemorrhage (ICH) is challenging. The purpose of this study was to evaluate the diagnostic accuracy of routine cerebrospinal fluid (CSF) studies including a cell index and a corrected white blood cell (WBC) count. Methods Case control study of adult patients with the diagnosis of ICH and HCAMV at a large tertiary care hospital in Houston, Texas from 2003 to 2016. Cases were defined as patients with ICH and HCAMV as documented by a positive CSF culture. Controls were selected as patients with ICH without evidence of HCAMV, no previous antibiotic therapy and a negative CSF culture. Cases and controls were matched 1:2 by age, Glasgow Coma Scale (GCS) and Apache II scores. Cell index was calculated using the following formula: (CSF leukocytes / CSF erythrocytes) / (blood leukocytes / blood erythrocytes). Corrected WBC count was calculated using the following formula: CSF leukocytes - (CSF erythrocytes/1,000). Area under the curve of receiver operating characteristic (AUC-ROC) and 95% confidence interval (CI) for CSF cell index greater than or equal to absolute value of 1, corrected CSF WBC count greater than 5 K/uL, CSF lactate greater than 4 mmol/L, and CSF glucose less than 40 mmol/L, respectively, were calculated in order to determine the accuracy of these studies. Results A total of 120 patients with ICH were included in this study; 40 patients had proven HCAMV whereas 80 patients had ICH with no evidence of HCAMV. Matching of cases and controls by age, GCS, and Apache II score was appropriate (p&amp;gt;0.05). The AUC-ROC values for CSF cell index, corrected CSF WBC count, CSF lactate, and CSF glucose were all low at 0.609 (95% CI = 0.449–0.768), 0.731 (95% CI = 0.589–0.872), 0.719 (95% CI = 0.573–0.864), and 0.609 (95% CI = 0.449–0.768), respectively. Conclusion This study demonstrated poor accuracy of CSF cell index, corrected CSF WBC count, CSF lactate, and CSF glucose in diagnosis of HCAMV after ICH. Disclosures R. Hasbun, Biomeriaux: Consultant, Consulting fee. Biofire: Speaker’s Bureau, Speaker honorarium. Merck: Speaker’s Bureau, Speaker honorarium. Pfizer: Speaker’s Bureau, Speaker honorarium. Medicine’s Co: Speaker’s Bureau, Speaker honorarium.

Pooled analysis of 899 nosocomial meningitis episodes from Turkey.

Healthcare-associated meningitis (HCAM) is a relatively rare entity with significant morbidity and mortality. The aim of this study was to systematically review the Turkish medical literature for acute nosocomial meningitis. One national (ULAKBİM) and two international (www.scopus.com and www.pubmed.com) databases were searched. In addition, abstracts of four national congresses held between 2004 and 2013 were searched for reports for HCAM meningitis. Data for 899 HCAM meningitis episodes were obtained from 24 reports. In terms of clinical findings, 177 of 216 (81.9%) had fever (>38 °C), 55 of 64 (85.9%) had high CRP levels, 105 of 132 had leukocytosis (>10,000/mm3), and 241 of 759 had shunt infection. Cerebrospinal fluid culture yielded a pathogen in 689 of 872 nosocomial meningitis episodes. The most common pathogen was Acinetobacter spp. (30.7%), followed by coagulase-negative staphylococci (21.2%) and Staphylococcus aureus (19%). Carbapenem resistance was reported in 18 of 48 (37.5%) Acinetobacter spp. Overall mortality was 160/593 (27%). Pathogen-specific mortality was 55.5% (30/54) for A. baumannii whereas it was 18.9% (7/37) for S. aureus and 2/17 (11,7%) for MRSA. Nosocomial meningitis is still a serious and highly fatal disease. More preventive measures should be sought to further decrease HCAM meningitis and the mortality/morbidity related to it.

Is First-Line Vancomycin Still the Best Option to Treat Staphylococcus Health Care–Associated Meningitis?

Cerebrospinal fluid (CSF) penetration of vancomycin through the blood-brain barrier is poor but important inflammation improved it. Hence, vancomycin is recommended for the treatment of community meningitis. However, what about mild inflammatory health care-associated meningitis? The aim of this study was to evaluate the impact of vancomycin diffusion on CSF in Staphylococcus epidermidis health care-associated meningitis. This was a retrospective study of all consecutive patients with S.epidermidis CSF shunt-associated infection, which was treated by continuous intravenous vancomycin after standard of care (60 mg/kg/d after a loading dose of 15 mg/kg). Patient outcome, CSF protein level, and vancomycin concentration in CSF and serum were assessed. We report 6 consecutives cases. Clinical and biologic manifestations were of mild intensity. Meningeal permeability was moderately altered with low CSF protein levels. Despite appropriate vancomycin dosage resulting in high serum concentrations, CSF remained below the S.epidermidis minimal inhibitory concentration. We propose to reassess vancomycin use as first-line therapy when meningeal inflammation is mild-to-moderate in favor of antibiotics, which have a better CSF penetration.