Ventriculostomy Infection Research Articles

Predictors of ventriculostomy infection in a large single-center cohort.

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI). The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018. A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1-47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44-50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0-1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6-87.1; p = 0.003). The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Prospective Evaluation of Ventriculostomy Infections.

Introduction: Hospital-acquired infections associated with external drainage of ventricular cerebrospinal fluid (CSF) are a significant source of concern for the patients and the provider team alike. Traditional rates of ventriculostomy infection range from 10-17% in a time-dependent fashion. Changing physician and nursing practices fueled this concern over infections. Objective: We sought to prospectively identify the risk factors associated with ventriculostomy infections as part of a quality assurance project. Methods: One hundred consecutive patients were evaluated and data were collected on 91. The primary indications for ventriculostomy were subarachnoid hemorrhage (46%), intracerebral hemorrhage (24%), and trauma (22%). Variables prospectively evaluated included pre-incision antibiotics, sterile technique bundling, setting of placement (operating room versus intensive care unit), experience of operator (attending, resident, or physician assistant), catheter type (antibiotic impregnated or not), use of a post-insertion dressing, and in-dwell time of the catheter. Results: There was only one infection in 91 patients (1.1%). This infection occurred in a patient without an antibiotic-impregnated catheter that was inserted by a resident physician. Compliance with pre-insertion antibiotics was very high, but most other variables had modest deviations in compliance.Conclusion: Infection rate related to external ventricular drainage is very low. Our data suggest that non-antibiotic impregnated catheters may be associated with infection, but that other variables thought to be critical may be of less value.

Ventriculostomy infections at the paediatric neurosurgical unit at Dr George Mukhari Academic Hospital

Background. External ventricular drains (EVDs) are essential to the clinical management and care of patients with neurosurgical complica­tions, but EVD use is routinely associated with concomitant infection, sometimes resulting in mortality. Objective. To undertake an epidemiological study of ventriculostomy-related infections among paediatric neurosurgical patients at the Dr George Mukhari Academic Hospital, Pretoria, South Africa. Methods. Retrospective analysis was conducted on the clinical records of 92 children admitted to the neurosurgical unit at the hospital between 2010 and 2013. Records were included in the study only if they were complete, legible and accurate. Data were collected on the following variables: age, gender, frequency of catheter change, cerebrospinal fluid (CSF) sampling, use of prophylaxis, microbiology, Glasgow Coma Scale, glucose, chlorine, and other clinical, chemical and laboratory parameters routinely observed as part of patients’ work-ups. Results. Two or more EVDs were placed on 45.7% (40) children, with a maximum of seven EVDs per child. Ventriculitis incidence was 28.3% (26 of 92). There was a significant association between the number of EVDs inserted and the incidence of ventriculitis ( p =0.010). More frequent CSF sampling also increased ventricular-related infections ( p =0.000), as did prolonged EVD retention ( p =0.001). Using prophylactic antibiotics or impregnated catheters did not reduce ventriculitis incidence significantly. Conclusion. Evidence supports adherence to strict sterilisation protocols and techniques when inserting EVDs. Catheters should not be retained for extended periods, and CSF sampling can be limited to once in 3 days. Routine use of antibiotic-impregnated EVDs and antistaphylococcal prophylaxis is still recommended.

Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management.

Background:External ventricular drainage (EVD) is the procedure of choice for the treatment of acute hydrocephalus and increased intracranial pressure in patients of subarachnoid hemorrhage (SAH) and intracerebral hemorrhage with hydrocephalus and its sequelae. We evaluated the use of EVD in patients of SAHs (spontaneous/posttraumatic with/without hydrocephalus), hypertensive intracerebral bleeds with interventricular extensions, along with evaluation of the frequency of occurrence of complications of the procedure, infectious and noninfectious, and their management.Methods:During the period of 2½ years, between September 2012 and February 2015, 130 patients were subjected to external drainage procedure and were prospectively enrolled in this study. Information was collected on each patient regarding age, sex, diagnosis, underlying illness, secondary complications, other coexisting infections, use of systemic steroids, antibiotic treatment (systemic and intraventricular), and whether any other neurosurgical procedures were performed within 2 weeks of EVD insertion or any time the duration of ventriculostomy.Results:The study population of 130 patients underwent a total of 193 ventriculostomies. Thirty-six patients had ventriculostomy infection (27.6%). Evaluation of the use of EVD was done by comparing preoperative and postoperative grading scores. Forty-nine patients survived and improved their score from Grade 3–5 to Grade 2–4. Twenty-nine patients were moderately disable, 16 were severely disable, and 5 were left in the vegetative state. Evaluation of outcome of patients revealed that there was an overall mortality of 61 (46.9%) patients both in the acute phase and later. 33 of the 39 patients having Glasgow Coma Score (GCS) 3–5 at the time of EVD insertion expired, as against 20 of the 51 patients in GCS 6–8. Patients in GCS 9–12 had an even better outcome, with 8 of the 35 patients in this group expiring.Conclusions:The use of EVD should be undertaken only in situation where it is absolutely necessary and ventriculostomy should be kept only for the duration required, and this should be monitored on a daily basis, given the exponential increase in infection after 5 days.

Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: A single-center observation

ObjectiveIntraventricular tissue plasminogen activator (alteplase) has been advocated for prevention of vasospasm in aneurysmal subarachnoid hemorrhage and treatment of traumatic or spontaneous intraventricular hemorrhage. External ventricular drain (EVD) insertion is often performed to manage increased intracranial pressure and hydrocephalus associated with these disease states. EVD-related ventriculitis is a serious infection with an up to 50% mortality rate. MethodsWe assessed the EVD infection rate in patients receiving intraventricular alteplase over a 12-month period. Patients were divided into intraventricular alteplase and non-intraventricular alteplase groups; ventriculitis rates were compared. ResultsEVDs were placed in 93 patients. Six of 7 (86%) patients who received intraventricular alteplase developed ventriculitis versus 4 of 86 (5%) patients in the non-intraventricular alteplase group (p<0.0001). ConclusionIntraventricular alteplase use may increase ventriculitis risk. Currently, we reserve intraventricular alteplase for patients with EVDs obstructed by hematoma accompanied by increased intracranial pressure.

Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution

Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated. A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period. At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation. Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

Ventriculostomy Infections and Complications: Surely We Should Be Doing Better?

Ventriculostomy Infections and Complications: Surely We Should Be Doing Better?

Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Impact of a standardized protocol and antibiotic-impregnated catheters on ventriculostomy infection rates in cerebrovascular patients.

Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters. To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters. Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5). The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5). The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

Are Ventriculostomy Infections Reduced by Standardized Protocols or by Antibiotic-Impregnated Catheters?

Are Ventriculostomy Infections Reduced by Standardized Protocols or by Antibiotic-Impregnated Catheters?

Polymerase Chain Reaction for the Rapid Detection of Cerebrospinal Fluid Shunt or Ventriculostomy Infections

Infection after cerebrospinal fluid (CSF) shunts or ventriculostomies is a common complication associated with significant morbidity and mortality. Polymerase chain reaction (PCR) is a powerful molecular technique that allows rapid and precise amplification of bacterial deoxyribonucleic acid (DNA) and has proven a powerful tool in the detection of a wide variety of clinically important infectious diseases. We analyzed specimens of CSF derived from ventriculoperitoneal shunts or external ventricular drains by using both conventional cultures and PCR and report herein our preliminary results. We selected 86 CSF samples from adult patients who underwent either shunt tap or routine surveillance cultures of their ventriculostomy. These specimens were chosen from a larger group of 300 specimens that were routinely collected (many serially) in our clinical practice. They were chosen because clinical suspicion of infection was increased because of either patient signs and symptoms (fever, stiff neck, lethargy, worsening neurological examination) or preliminary laboratory analysis of CSF data (increased white blood cell count, increased protein level, decreased glucose). We considered this subgroup optimal to efficiently initiate our investigation of the correlation of PCR and culture results. CSF was increased by using standard culture techniques and by using PCR. Samples of CSF that were to undergo PCR had DNA extracted, purified, and amplified for 16S rRNA using primers 16S-Forward and 16S-Reverse of conserved sequence regions of all bacteria. DNA was PCR-amplified for 30 cycles. One microliter of the first PCR product was subjected to nested PCR using primers specific for gram-positive and gram-negative bacteria. Samples were also subjected to PCR amplification for specific detection of Propionibacterium acnes, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus using specific primers for 16S rRNA Propionibacterium, nuclease gene of Staphylococcus, and Mec gene of methicillin-resistant Staphylococcus aureus. For 18 of 86 specimens (21%), both the culture and PCR were positive. For 30 of 86 specimens (35%), both the PCR and culture results were negative. For 42 of 86 specimens (49%), cultures were negative and PCR was positive. There were no positive culture results with negative PCR results. Most negative culture/positive PCR cases occurred after prolonged intravenous antibiotics. Of the 56 PCR-positive specimens, 30 were positive for Propionibacterium acnes, whereas 40 were positive for Staphylococcus aureus. Of the Staphylococcus aureus-positive specimens, two were positive for methicillin resistant-Staphylococcus aureus. Among the 56 PCR-positive specimens, 30 were positive for both Propionibacterium acnes and Staphylococcus aureus; gram-negative organisms were not detected by any method in these specimens. These preliminary data suggest that PCR is a highly sensitive, rapid, and potentially promising modality for the detection and treatment of CSF shunt ventriculostomy infection.

Polymerase chain reaction (PCR) for rapid detection of cerebrospinal fluid shunt or ventriculostomy infections

Abstract Introduction: Infections of cerebrospinal fluid (CSF) shunts or ventriculostomies are common complications that are associated with significant morbidity and mortality. Detection of infection may be difficult or delayed as it requires colonial growth of microorganisms in culture medium. PCR provides rapid and accurate detection of bacterial DNA. Methods: Under Institutional Review Board approval (X030403011), 50 samples of CSF samples were collected (many serially) from adult patients who underwent either shunt tap or routine surveillance cultures of their external ventricular catheter. CSF was evaluated by standard culture techniques and by PCR. For PCR, frozen samples of CSF were thawed on ice and DNA extracted, purified and amplified for 16S rRNA using primers 16S-Forward and 16S-Reverse of conserved sequence region of all bacteria. DNA was PCR amplified for 30 cycles (denaturation at 94degC/15sec, annealing at 54degC/15sec, extension at 72degC/30sec) after initial denaturation at 94degC/5min. One microliter of the 1st PCR product was subjected to nested PCR using primers specific for Gram+ve, Gram−ve bacteria and P. acnes, S. aureus, and MRSA. Results: For 13/50 specimens, both culture and PCR were positive. For 18/50 specimens both PCR and culture results were negative. For 19/50 specimens, cultures were negative and PCR was positive. Conclusions: There were no positive culture results with negative PCR and the negative culture/positive PCR cases occurred after prolonged iv antibiotics. These preliminary data suggest that PCR is a highly sensitive, rapid and potentially useful modality for the detection of CSF shunt or ventriculostomy infection.

Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients.

The investigators undertook a retrospective analysis of ventriculostomy infections to evaluate their relationship to monitoring duration and prophylactic catheter exchange. In 1984, the results of an epidemiological study of ventriculostomy-related infection were published. One of the conclusions of the paper was that the incidence of ventriculostomy-related infections rose after 5 days of monitoring. This led to the recommendation that catheters be prophylactically changed at 5-day intervals if prolonged monitoring was required. A recent randomized prospective study on central venous catheters showed no reduction in infection with prophylactic catheter exchanges. This has led the authors to reexamine their experience with ventriculostomy infections. Data on 584 severely head injured patients with ventriculostomies were prospectively collected in two data banks, The Traumatic Coma Data Bank and The Medical College of Virginia Neurocore Data Bank. These data were retrospectively analyzed for factors associated with ventriculostomy related infections. It was found that there is a relationship of ventriculitis to monitoring duration but it is not simple or linear. There is a rising risk of infection over the first 10 days, but infection then becomes very unlikely despite a population that continues to be at risk. Patients in whom catheters were replaced prior to 5 days did not have a lower infection rate than those whose catheters were exchanged at more than 5-day intervals. Based on these data, it is recommended that ventriculostomy catheters for intracranial pressure monitoring be removed as quickly as possible, and in circumstances in which prolonged monitoring is required, there appears to be no benefit from catheter exchange.

Invasive group B streptococcal disease in children beyond early infancy.

There is little information available on invasive group B Streptococcus (GBS) infection in pediatric patients older than 3 months of age. Review of infection control records at LeBonheur Children's Medical Center from January 1, 1986, to June 30, 1993, identified 143 patients with a positive GBS culture from normally sterile body fluid. Medical records of 18 (13%) patients > 3 months old with their first GBS infection were reviewed. Age range was 15 weeks to 18 years (median age, 13 months). Ten were black and 11 were girls. Five infants had a history of premature birth and 2 infants were infected with human immunodeficiency virus. The serotype distribution of 12 available GBS isolates was 4 type III, 2 each type V and Ia and 1 each type Ia/c, Ib/c, II and II/c. Bacteremia without a focus (9 patients) was the most common clinical manifestation. All 4 type III isolates were associated with bacteremia. One infant with human immunodeficiency virus infection had sepsis and bullous desquamation; a toxin-producing type V strain was isolated from her blood. Two adolescents with ventriculoperitoneal shunts had meningitis, including one whose cerebrospinal fluid also grew a type V strain. Other clinical manifestations were septic arthritis, endocarditis (Ia, II/c), central venous catheter (Ia/c) and ventriculostomy infections.

Relative risks of ventriculostomy infection and morbidity.

Ventricular catheter placement is a common procedure for the management of increased intracranial pressure. Hypotheses regarding the etiology of infection of catheters center on two alternative assumptions: 1) contamination leading to infection occurs at the time of catheter insertion, implying that catheter duration has minimal effect on infection risk; and 2) infection of catheters derives from catheter contamination after insertion, suggesting that duration of catheter use may significantly affect infection risk. We have studied the relative complication rate of ventricular catheter insertions using a retrospective approach (n = 161 patients and 253 catheter insertion procedures). The overall infection rate was 4.1%, but the daily infection hazard increased exponentially with time, to a maximum daily rate of 10.3% by day 6 of catheter insertion. This increasing risk appears most consistent with the second hypothesis. The risk of non-infectious complications was 5.6%, including hemorrhagic occurrences and misplacement severe enough to require a new catheter insertion. The daily hazard of infection approximately equalled the non-infectious risk of routine catheter replacement by day 5. Additional prospective data on the daily risk of CSF infection and the appropriateness of antibiotic prophylaxis either at the time of ventricular catheter insertion or continued through the catheter's presence may be required to both definitively identify which hypothesis of infection risk is correct and whether antibiotics can significantly ameliorate this risk.

Corynebacterium JK: A new pathogen in ventriculostomy infections

In the past decade, Corynebacterium JK has emerged as a pathogen in several distinct clinical settings, including sepsis in immunocompromised patients and prosthetic valve endocarditis. It is also recognized as a nosocomial pathogen in infections of prosthetic devices. We present a case of a patient with carcinomatous meningitis who developed a Corynebacterium JK infection of an internal ventriculostomy which was used for intraventricular chemotherapy. Treatment with systemic and intraventriculostomy vancomycin for three weeks resulted in bacteriologic resolution of the infection. Removal of the prosthetic device was not essential for cure in this patient. The clinical spectrum of infection with this organism and aspects of therapy are reviewed. As a greater awareness of the pathogenic nature of this organism develops, it is likely to be implicated as a causative agent in a variety of infections.

Penetration of cefuroxime into ventricular fluid in cerebrospinal fluid shunt infections

The penetration of intravenously administered cefuroxime into ventricular fluid was assessed in five pediatric patients with ventriculoperitoneal shunt infections and in one with a ventriculostomy infection. Patients received a total dose of 200 to 230 mg of cefuroxime per kg of body weight per day administered at 8-h intervals. Levels of cefuroxime in ventricular fluid ranged from 1.6 to 22.5 micrograms/ml and were associated with cerebrospinal fluid bactericidal titers ranging from less than 1:2 to 1:16 against infecting staphylococcal isolates. Five infections were cured with cefuroxime monotherapy. On the basis of MIC data, one patient had vancomycin substituted for cefuroxime and the infection was cured.

Plasmid-pattern analysis for the differentiation of infecting from noninfecting Staphylococcus epidermidis.

Isolation of Staphylococcus epidermidis from cultures of blood was differentiated from culture contamination by the detection of identical isolates in two or more consecutive cultures from an infected patient. We used plasmid-pattern analysis as a tool for establishing the identity of individual isolates. In a control study of 15 patients with two or more cultures of blood contaminated with S. epidermidis, analysis revealed that none of the isolates had identical plasmid patterns. This reflected the variety of plasmid patterns among colonizing coagulase-negative staphylococci cultured from skin sites of uninfected patients. In contrast, plasmid-pattern identity was seen among sequential or paired S. epidermidis isolates from a given patient in 32 of 36 patients with documented S. epidermidis infection. The plasmid pattern of each set of isolates from patients was unique. Infections included prosthetic-valve endocarditis in 26 patients, cerebrospinal fluid-shunt or ventriculostomy infections in six patients, intravenous-catheter sepsis in two patients, urinary tract infection in one patient, and osteomyelitis in one patient. Plasmid-pattern analysis may therefore be useful in the diagnosis of S. epidermidis infections.