Intraventricular Antibiotic Treatment Research Articles

Current Practices of Intraventricular Antibiotic Therapy in the Treatment of Meningitis and Ventriculitis: Results from a Multicenter Retrospective Cohort Study.

Central nervous system (CNS) infections are particularly prevalent in the adult neurocritical care patient population and are associated with significant morbidity and mortality. Factors relevant to the nature of CNS infections pose significant challenges to clinicians treating afflicted patients. Intraventricular (IVT) administration of antibiotics may offer several benefits over systemic therapy; however, the outcomes and current practices of such treatments are poorly described in the literature. To describe current practices and outcomes of patients receiving intraventricular antibiotic treatment for CNS infections in neurological intensive care units of academic medical centers nationwide. A retrospective cohort study was conducted on patients admitted to intensive care units who received IVT antibiotic treatment at participating centers in the USA between January 01, 2003, and December 31, 2013. Clinical and laboratory parameters, microbiology, surgical and antimicrobial management, and treatment outcomes were collected and described. Of the 105 patients included, all received systemic antimicrobial therapy along with at least one dose of IVT antimicrobial agents. Intraventricular vancomycin was used in 52.4% of patients. The average dose was 12.2mg/day for a median duration of 5days. Intraventricular aminoglycosides were used in 47.5% of the patients, either alone or in combination with IVT vancomycin. The average dose of gentamicin/tobramycin was 6.7mg/day with a median duration of 6days. Overall mortality was 18.1%. Cerebrospinal fluid (CSF) culture sterilization occurred in 88.4% of the patients with a rate of recurrence or persistence of positive cultures of 9.5%. Intraventricular antimicrobial agents resulted in a high CSF sterilization rate. Contemporary use of this route typically results in a treatment duration of less than a week. Prospective studies are needed to establish the optimal patient population, as well as the efficacy and safety of this route of administration.

Diagnosis and treatment of severe neurosurgical patients with pyogenic ventriculitis caused by gram-negative bacteria

The aim of the study is to explore the experiences in diagnosis and treatment of severe neurosurgical patients with pyogenic ventriculitis caused by gram-negative bacteria (G-). Nineteen patients with pyogenic ventriculitis were reviewed for their treatment. The bacterial testing results of cerebrospinal fluid (CSF), the clinical intervention, and the patients' prognosis were evaluated. The bacterial smears of ventricular drainage from all the cases were G- bacteria. Head CT and MRI scans confirmed that they were intraventricular empyema. Eighteen cases of CSF bacterial test were positive, including 12 cases of Acinetobacter baumannii positive, 2 of Klebsiella pneumonia positive, 2 of Serratia marcescens positive, 1 of Pseudomonas maltophila positive, and 1 case of Escherichia coli positive. One case of the bacterial culture was negative. All patients were treated by using intraventricular lavage in combination with intravenous and intraventricular antibiotics in accordance with the clinical conditions. After treatment for 2 to 8weeks, 14 patients were cured (74%) and 5 were died (26%). Eight patients who were cured had received ventriculoperitoneal shunt due to hydrocephalus at 2 to 6weeks after infection controlled, and none of them had any reinfection. Twelve of the 14 cured cases came to consciousness, but 2 were persistent in vegetative state starting before the infection; they did not show any improving consciousness after infection had been cured. Suppurative ventriculitis in severe neurosurgical patients is mainly infected by G- with a higher mortality. Early diagnosis, especially in identifying pathogen types, timely ventricular irrigation, and ventricular drainage together with intravenous and intraventricular antibiotic treatment, should improve prognosis.

Diagnosis and treatment of pyogenic ventriculitis caused by gram-negative bacteria in severe neurosurgical patients

Objective To investigate the experiences in diagnosis and treatment pyogenic ventriculitis caused by gram-negative bacteria (G-) in severe neurosurgical patients. Methods Nineteen consecutive patients with pyogenic ventriculitis treated at the Neurosurgical Intensive Care Unit of the Department of Neurosurgery, Beijing Xuanwu Hospital, Capital Medical University from September 2009 to August 2014 were reviewed. Their bacteriological results, clinical treatment, and prognosis were analyzed. Results Ventricular drainage of cerebrospinal fluid bacterial smears in all cases were G-bacteria. Head CT scans confirmed as intraventricular empyema. Eighteen patients were positive in cerebrospinal fluid bacterial culture, 12 of them were Acinetobacter baumannii, 2 were Klebsiella pneumonia, 2 were Serratia marcescens, 1 was Pseudomonas maltophila, and 1 was Escherichia coli. The bacterial culture in one case was negative. The catheters which caused infections were removed and ventricular drainage was conducted in all cases. The patients were treated with intraventricular lavage in combination with intravenous drugs and intraventricular antibiotics according to the conditions. They were followed up for 3 months to 3 years. After treatment for 2 to 8 weeks, 14 patients were cured (74%) and 5 died (26%). In the cured patients, 8 patients underwent ventriculo-peritoneal shunt after the infection being cured in 2 to 6 weeks because of hydrocephalus. No reinfection occurred. Twelve patients came to consciousness, and 2 were in a persistent vegetative state before infection and did not have any improvement. Conclusions Suppurative ventriculitis in severe neurosurgical patients is mainly caused by G-negative bacteria. The mortality is higher. Early diagnosis, especially clarifying pathogens, timely ventricular irrigation, and ventricular drainage in combination with intravenous and intraventricular antibiotic treatment may increase the cure rate and improve the prognosis. Key words: Cerebral ventriculitis; Gram-negative bacteria; Intensive care unit; Acinetobacter baumannii

Intraventricular antimicrobial therapy in postneurosurgical Gram-negative bacillary meningitis or ventriculitis: A hospital-based retrospective study

Postneurosurgical Gram-negative bacillary meningitis (GNBM) or ventriculitis is a serious issue. Intraventricular (IVT) therapy has been applied; however, its effectiveness remains controversial, and the adverse drug effects are considerable. The demographic data, treatment strategies, and clinical outcomes of patients with postneurosurgical GNBM or ventriculitis were recorded. From 2003 to 2011, data on 127 episodes of infection in 109 patients were collected, and 15 episodes in 14 patients were treated using a sequential combination of intravenous antibiotics and IVT therapy; others received intravenous antibiotics alone. The average age of patients who received a sequential combination with IVT therapy was 48.9 years, and 71.4% of the patients were men. The regimens used for IVT therapies included gentamicin (n = 4), amikacin (n = 7), and colistin (n = 4). After meningitis had been diagnosed, the average period that elapsed before initiation of IVT therapy was 25.4 days, and the average duration of IVT therapy was 13.3 days. The most frequently isolated pathogen from cerebrospinal fluid (CSF) was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Serratia marcescens. The cure rate was 73.3%. Of note, the mean period to sterilize the CSF after appropriate IVT antibiotic treatment was 6.6 days. There were no incidents of seizure or chemical ventriculitis during this IVT therapy. The findings of this study suggest that IVT antibiotic therapy is a useful option in the treatment of postneurosurgical GNBM or ventriculitis, especially for those with a treatment-refractory state.

Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents

Infection represents the most common serious complication of shunt surgery, and typically its incidence ranges between 5 and 15%, despite the use of systemic antibiotic agents. Because systemic antibiotic medications generally penetrate the cerebrospinal fluid (CSF) poorly, the authors investigated, in a controlled study, whether the addition of intraventricular antibiotic treatment decreases the incidence of perioperative infection in adult patients. Data pertaining to all CSF shunt procedures conducted at the authors' institution during an 11-year period were reviewed. Perioperative infection was defined as culture-positive CSF and the clinical presence of infection-related symptoms occurring within 90 days of surgery. All patients underwent intraoperative systemic antistaphylococcal antibiotic therapy. Before May 16, 1999, the senior author (R.H.S.) also administered 4 mg of gentamicin intraventricularly at surgery (Group I); thereafter, 10 mg of vancomycin was additionally administered (Group II). Other neurosurgeons at this institution did not use intraventricular antibiotic therapy, and their patients served as additional controls in identical time periods (Groups III and IV). A total of 802 shunt procedures were performed in 534 patients. Control infection rates were 5.4% (eight of 147) in Group I; 6.2% (nine of 145) in Group III; and 6.7% (18 of 267) in Group IV. With the combination of systemic antibiotic and intraventricular gentamicin and vancomycin (Group II), the infection rate fell significantly to 0.4% (one of 243). No complications were noted in association with intraventricular antibiotic administration. The combination of intraventricular gentamicin and vancomycin with systemic antibiotic therapy significantly decreased the incidence of perioperative shunt infection. It is presumed that intraventricular antibiotic therapy extends prophylactic antibiotic coverage into the CSF and prevents bacterial seeding.

Staphylococcus aureus Meningitis: Experience with Cefuroxime Treatment During a 16 Year Period in a Danish Region

Staphylococcus aureus is a rare cause of bacterial meningitis and there is no consensus on antibiotic treatment. Nafcillin is a common choice in countries where it is approved and marketed. High-dose cefuroxime has been the systemic treatment used in the study region, and a retrospective record review was conducted to determine its clinical efficacy. Cases of bacterial meningitis during 1984-1999 in the County of North Jutland, Denmark (approx. 490000 inhabitants), were identified in a regional bacteriology register. Inclusion of a case required either growth of S. aureus from > or = 2 specimens of cerebrospinal fluid (CSF), 1 positive CSF specimen with a CSF leucocyte count > 10(8)/l or 1 positive CSF specimen with a concurrent positive blood culture. A diagnosis of brain abscess required growth of S. aureus from aspirated pus. Staphylococcus aureus meningitis was confirmed in 45 patients, and 5 additional patients had a brain abscess. 44 cases were nosocomial (mortality 16%) and 6 were community acquired (mortality 83%). None of the isolates was methicillin resistant and 6 were penicillin susceptible. Intraventricular antibiotic treatment was given to 28 patients, systemic therapy included cefuroxime in 32 patients (64%) as either a primary or secondary choice, 6 (12%) were treated with penicillin G, 10 (20%) with penicillinase-resistant penicillin and 2 (4%) with cephalothin. Among 31 nosocomial cases treated systemically with cefuroxime the mortality was 10% (95% exact confidence limits 2-26%). In conclusion, cefuroxime seems to be a valid choice for S. aureus meningitis in the nosocomial setting.

Infections in neurosurgery: a retrospective study of 1143 patients and 1517 operations.

The files of 1143 neurosurgical patients, operated on between November 1, 1979 and June 4, 1981 were examined for records of post-operative infections. Eighty-three patients had developed infections (7%). In addition there were 33 instances of aseptic meningitis. Patients with a shunt were prone to infection (12%). Bone flap infections accounted for more than half of all infections after supratentorial craniotomy. Bacterial meningitis accounted for more than half of all infections after suboccipital craniotomy and translabyrinthine operations. In these patients bacterial meningitis was six times more common, and aseptic meningitis three times more common than in those who had had supratentorial operations. Shunt infection was more common after repeated shunt operations in quick succession. Craniotomy increased the risk of a shunt becoming infected. Antibiotic prophylaxis should be used not only in shunt operations but in all operations performed on patients with a shunt. If bacteria are recovered in a suspected shunt infection, immediate removal of the shunt is the best treatment. However, if the shunt's removal or replacement is exceptionally difficult intraventricular antibiotic treatment may be tried. The age of the patient, the duration of the operation, the individual surgeon and the number of operations did not affect the rate of infection. Clinical signs and conventional laboratory tests, apart from bacterial culture, cannot differentiate between bacterial and aseptic meningitis, but a drop in the level of consciousness suggests bacterial meningitis.

Salmonella meningitis in infancy.

Despite adequate treatment, mortality and morbidity were high among the 13 cases of Salmonella meningitis in this series. Chloramphenicol, being a bacteriostatic agent against Salmonella species, is not a suitable antibiotic for the treatment of Salmonella meningitis. Treatment for 4-6 weeks is recommended with use of an antibiotic capable of achieving an adequate bactericidal concentration in the cerebrospinal fluid such as moxalactam. Intraventricular antibiotic treatment should be considered if there is a delay in the eradication of the Salmonella organisms from the cerebrospinal fluid after starting treatment.