Ventriculostomy-related Infections Research Articles

Pathophysiology and Prevention of Ventriculostomy-Related Infections: A Review.

This qualitative review aims to summarize current knowledge on ventriculostomy-related infection (VRI) pathophysiology and its prevention. VRI generally occurs at day 10, mainly because of Gram-positive cocci, after a cerebrospinal fluid leak. Skin microbiota and biofilm seem to play a major role in VRI pathogenesis. Colonization of external ventricular drain by biofilm is universal and occurs quickly after catheter insertion. However, pathogens from the skin are more often associated with VRI than commensal bacteria. A review of proposed preventive measures shows that none has proven to be fully efficient. Periprocedural and prolonged systemic prophylactic antimicrobials have not shown to prevent VRIs and may promote the emergence of more resistant or pathogenic strains. Antimicrobial and silver-impregnated external ventricular drains, although promising, have not demonstrated preventive effects and may modify bacterial ecology. These results are consistent with the proposed pathophysiology. Finally, we will present a few propositions for future research that may help in improving our knowledge and thus better prevent VRIs. Until then, given the available data, limiting the duration of ventricular drainage may be the most attainable option to prevent VRIs.

Broad Range Eubacterial Polymerase Chain Reaction of Cerebrospinal Fluid Reduces the Time to Exclusion of and Costs Associated with Ventriculostomy-Related Infection in Hemorrhagic Stroke

BackgroundPatients with hemorrhagic stroke and an external ventricular drain in situ are at risk for ventriculostomy-related-infections (VRI). Because of the contamination of the cerebrospinal fluid (CSF) with blood and the high frequency of false negative CSF culture, the diagnosis of VRI remains challenging. This study investigated the introduction of CSF broad range eubacterial polymerase chain reaction (ePCR) and its effect on frequency and duration of antibiotic therapy for VRI, neurocritical care unit (NCCU) length of stay, related costs, and outcome.MethodsBetween 2020 and 2022, we prospectively included 193 patients admitted to the NCCU of the University Hospital of Zürich with hemorrhagic stroke and an external ventricular drain for more than 48 h. Patient characteristics, serum inflammatory markers, white blood cell count in CSF, use and duration of antibiotic treatment for VRI, microbiological findings (CSF cultures and ePCR tests), and NCCU length of stay were compared in patients with no infection, noncerebral infection, suspected VRI, and confirmed VRI. Data of patients with suspected VRI of this cohort were compared with a retrospective cohort of patients with suspected VRI treated at our NCCU before the introduction of CSF ePCR testing (2013–2019).ResultsOut of 193 patients, 12 (6%) were diagnosed with a confirmed VRI, 66 (34%) with suspected VRI, 90 (47%) with a noncerebral infection, and 25 (13%) had no infection at all. Compared with the retrospective cohort of patients, the use of CSF ePCR resulted in a reduction of patients treated for suspected VRI for the whole duration of 14 days (from 51 to 11%). Furthermore, compared with the retrospective group of patients with suspected VRI (n = 67), after the introduction of CSF ePCR, patients with suspected VRI had shorter antibiotic treatment duration of almost 10 days and, hence, lower related costs with comparable outcome at 3 months.ConclusionsThe use of CSF ePCR to identify VRI resulted in shorter antibiotic treatment duration without changing the outcome, as compared with a retrospective cohort of patients with suspected VRI.

Impact of Subarachnoid Hemorrhage in Ventriculostomy-Related Infections Prospective Comparison of Two Neurosurgical Injury Contexts

Long thought to be immune privileged, the central nervous system is far from being devoid of local immunity. Subarachnoid hemorrhage (SAH) and traumatic brain injury represent 2 distinct central nervous system injury situations which, while both exposed to external ventricular drains, present different incidences of ventriculostomy-related infection (VRI). We sought to compare VRI incidence and initial cerebrospinal fluid (CSF) inflammatory profiles in these 2 clinical situations. From 2015 to 2020, 227 patients treated for SAH (193) or traumatic brain injury (34) with an external ventricular drain were prospectively included. CSF samples were sent daily for microbiological examination, cell count, and biochemical analysis. VRI was defined as a positive CSF culture associated with CSF profile modifications and clinical signs. Ventriculostomy-related colonization was defined as positive catheter culture at removal. Positive events were defined as VRI and/or ventriculostomy-related colonization. Eleven patients suffered from VRI, with an incidence of 3.6 VRI per 1000 catheter-days. All VRIs occurred among SAH patients without a significant difference. Median duration of drainage was 12 (7-18) days, there were no significant differences for known VRI risk factors. Positive events were significantly higher in SAH patients (20.7% vs. 2.9%, P= 0.013). Inflammatory CSF markers and serum white blood cells were higher in SAH patients. Local inflammatory markers were markedly higher in SAH than in traumatic brain injury. However, positive events were more frequent in SAH. Furthermore, SAH may be a risk factor for VRI. Hypothesis that a primary injury to the subarachnoid space could impair central nervous system immune functions should be explored.

Ventriculostomy-Related Infections: Reduced Incidence by Terminating Cerebrospinal Fluid Screening

The external ventricular drain (EVD) is an important instrument in managing patients in neurointensive care (NICU). A frequent and sometimes severe complication is ventriculostomy-related infection (VRI). This study aimed to evaluate the effects of biweekly VRI screening by CSF sampling on the clinical course and rate of VRI. Patients with implanted EVDs were retrospectively identified and a cohort screened twice per week was compared with a cohort sampled only on clinical indication. VRI was defined either as a suspected case or a culture-confirmed case. Length of stay in the NICU and CSF shunt dependency were used as outcome parameters. A total of 562 patients were included. The overall proportion of patients treated for VRI was 22% and was not affected by screening (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.57-1.54). Screening was associated with a higher proportion of patients with culture-confirmed VRI (OR, 2.86; 95% CI, 1.36-6.73). The main risk factor for VRI was the number of days with EVD. Positive bacterial culture was associated with both a longer time in the NICU (β= 3.6; P < 0.01) and higher risk for shunt surgery (OR, 1.95; 95% CI, 1.04-3.64). Screening was associated with a higher number of culture-confirmed VRI cases. In addition, screening did not detect VRI at an earlier stage and was not associated with a reduction in the rate of permanent hydrocephalus. No clinical benefit of screening was found. Frequent CSF sampling might contribute to infection. Based on these findings, CSF screening for VRI cannot be recommended.

Prospective Comparative Study of External Ventricular Drain Catheter Colonization: Antibiotic-Impregnated versus Conventional Drains

Our aim was to compare the prevalence of biofilm formation on antibiotic-impregnated (AIC) versus standard (SC) external ventricular drain (EVD) catheters. From March 2018 to November 2020, all consecutive EVD catheters inserted in adult patients were included. After removal, EVD catheters were analyzed under scanning electronic microscopy, on both extraluminal and intraluminal faces. Standard culture of catheter tips was also performed. Overall, 114 catheters were included in 101 patients. There were 48 AICs and 66 SCs. Standard culture showed that ventriculostomy-related colonization was more frequent in SC than in AIC (26 vs. 10%; P= 0.06). Gram-negative rods accounted for 25% of ventriculostomy-related colonization in AICs, and none was documented in SCs. Scanning electronic microscopy observation showed mature biofilm on more than 80% of catheters, without significant difference between catheter type. Also, there was no difference between extraluminal and intraluminal colonization rate. There were 2 ventriculostomy-related infections in each group (5% and 3% among AICs and SCs respectively; P= 1). Mature biofilm presence on the intraluminal and the extraluminal faces is similar on AICs and SCs. Accordingly, AICs do not seem to efficiently prevent biofilm formation on EVD catheters. The impact of AICs on the microbiological epidemiology of colonizing biofilm should be further evaluated.

Heparin-binding protein as a marker of ventriculostomy related infection and central nervous system inflammation in neuro-intensive care

ObjectiveDiagnosis of ventriculostomy related infections (VRI) in the neuro-intensive care unit remains challenging and current biomarkers lack adequate precision. The aim of this study was to explore the potential of Heparin-binding protein (HBP) in cerebrospinal fluid (CSF) as a diagnostic biomarker of VRI. MethodsAll patients treated with an external ventricular drain (EVD) between January 2009 and March 2010 at Skåne university hospital in Lund, Sweden, were consecutively included. CSF samples obtained during routine care were analyzed for HBP. VRI was defined as a positive bacterial microbiology test result on a CSF sample with an erythrocyte-corrected leukocyte count of > 50 × 106/l. HBP levels at VRI diagnosis was compared to peak HBP levels in non-VRI controls. ResultsIn total, 394 CSF samples from 103 patients were analyzed for HBP. Seven patients (6.8%) fulfilled VRI criteria. Levels of HBP were significantly higher in VRI subjects (31.7 ng/mL [IQR 26.9–40.7 ng/mL]) compared to non-VRI controls (7.7 ng/mL [IQR 4.1–24.5 ng/mL]) (p = 0.024). The AUC of the receiver operating characteristic (ROC) curve was 0.76 (95% confidence interval [CI], 0.62–0.90). Among non-VRI patients, HBP was highest in patients with acute bacterial meningitis. Patients with subarachnoid hemorrhage displayed higher HBP levels than those with traumatic brain injury or shunt dysfunction. ConclusionsHBP levels were higher in VRI subjects and varied between patients and different diagnoses. To validate the clinical usefulness and added value of HBP as a biomarker for VRI, the results need to be confirmed in larger studies with head-to-head comparisons to current biomarkers.

The impact of subarachnoid and ventricular hemorrhage extension on ventriculostomy-related infections in patients with aneurysmal subarachnoid hemorrhage

The impact of subarachnoid and ventricular hemorrhage extension on ventriculostomy-related infections in patients with aneurysmal subarachnoid hemorrhage

Prevalence of Ventriculostomy Related Infections and Associated Factors in Low Income Setup.

Ventriculostomy, a lifesaving and emergency procedure, is used to address raised intracranial pressure. In resource limited set-up like Tikur Annbessa Specialized Referral Hospital, properly designed closed system for ventriculostomy is not available; a device made with sterile pediatric nasogastric tube connected to urine bag is used. Institutional based retrospective cross-sectional study conducted on 93 patients with ventriculostomy from January 1, 2009 to June 30, 2018. Ventriculostomy related infection risk described in descriptive statistics and Binary Logistic Regression analysis. The prevalence rate of Ventriculostomy related infection is 25.8% at Tikur Annbessa Specialized Referral Hospital. Identified risk factors: Ventriculostomy stay for five or more days (AOR=7.676, 95% CI: 1.424, 41.367) and cerbro-spinal fluid leak (AOR=4.592, 95% CI: 1.279, 16.488). Ventriculostomy manipulation showed association on bivariate analysis. K.Pneumoniae (34.6%) and Acinetobacter spp. (30.8%) identified as the main organisms. They were sensitive to combined ceftazidime and vancomycin in 19.2% and meropenem in 42.3%. Based on Tängdén's criteria, 11.8% of patients died of Ventriculostomy related infection while 43% of the patients died in total. Mortality from Ventriculostomy related infection is 45.8% once diagnosed. The prevalence rate of Ventriculostomy related infection is 25.8% at Tikur Annbessa Specialized Referral Hospital. The duration of external ventricular drain and Cerebrospinal fluid leak are identified risk factors. Ventriculostomy related infection is responsible for one third of mortality related with external ventricular drain. The remaining two third exact causes are not known.

An Integrative Review: Early Mobilization of Patients With External Ventriculostomy Drains in the Neurological Intensive Care Unit.

BACKGROUND: Patients in the intensive care unit (ICU) are at a high risk for immobility due to their high acuity and need for invasive devices including external ventriculostomy drains (EVDs). Prolonged patient immobilization is associated with poor outcomes. METHODS: Whittemore and Knafl's 5-stage framework was used to conduct an integrative review to synthesize findings from quantitative research studies on early patient mobilization for patients with EVDs in the neurological ICU. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used as the reporting guideline. RESULTS: In 12 studies, a total of 412 patients with EVDs in neurological ICUs were actively mobilized with a goal of progressing to ambulation. Mobilization out of bed with a ventriculostomy drain was safe and feasible without significant adverse events. CONCLUSION: There is a need to clarify best practices for early mobilization of patients with EVDs in the neurological ICU and to explore the influence of early mobilization on patients' rates of venous thromboembolism, catheter-associated urinary tract infections, catheter line-associated blood stream infections, ventilator-associated pneumonia, and ventriculostomy-related infections. No studies measured the total time the EVD was clamped during the patient mobilization intervention or the total amount of cerebrospinal fluid drainage on the day of mobilization. Early mobilization of patients with EVDs in the neurological ICU who were permitted out of bed was universally safe and feasible, with minimal adverse events when safety checks were integrated into mobilization protocols.

In Reply: Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases.

Background External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. Objective To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. Methods We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. Results Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. Conclusion Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases.

External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (>24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Durability of antimicrobial activity of antibiotic-impregnated external ventricular drains: a prospective study.

Antibiotic-impregnated external ventricular drains (AI-EVDs) have a debated efficacy in clinical studies. Our aim was to assess the durability of antimicrobial activity of AI-EVDs used in clinical settings. From April 2017 to January 2018, all consecutive AI-EVDs (Bactiseal™) inserted in adult patients were prospectively included. After removal, each AI-EVD was cultured and assessed for antimicrobial activity on both internal and external sides of AI-EVDs. Catheters were each challenged with a single Staphylococcus strain [MSSA, MRSA or methicillin-resistant Staphylococcus epidermidis (MRSE)]. MS was used to measure residual concentrations of rifampicin and clindamycin. Sixty-five AI-EVDs were included (56 patients). Among these, 21 were challenged with MSSA, 23 with MRSA and 21 with MRSE. Five ventriculostomy-related colonizations (9%) and two ventriculostomy-related infections (4%) occurred. Staphylococcus was the main bacterium responsible for colonization (4/5). AI-EVD inhibition decreased significantly against MRSA and MRSE according to duration of catheterization (for external and internal sides, P < 0.02) and overall volume of CSF drained (P < 0.005 for both sides against MRSE, P < 0.005 for external side against MRSA), but not against MSSA. Clindamycin concentration was not correlated with duration of catheterization or CSF volume drained, but <20% of initial concentration was recovered even after 5 days of AI-EVD dwelling. Conversely, rifampicin concentration showed a rapid and significant decline correlated to duration and CSF volume (P < 0.001 and P = 0.03, respectively). Antimicrobial activity of AI-EVDs dropped quickly in vivo. Antimicrobial impregnation did not prevent AI-EVD colonization by susceptible strains in 9% of the cases.

Peripheral white blood cell count as a screening tool for ventriculostomy-related infections

One of the most common complications following external ventricular drain (EVD) placement is infection. Routine cultures of cerebrospinal fluid (CSF) are often used to screen for infection, however several days may pass before infection is discovered. In this study, we compared the predictive value of daily recorded vital sign parameters and peripheral white blood count (WBC) in identifying ventriculostomy-related infections. Patients with EVDs who had CSF cultures for microorganisms performed between January 2011 and July 2017 were assigned to either an infected and/or uninfected study group. Clinical parameters were then compared using t-test, chi squared and multiple logistic regression analyses. Patients of any age and gender were included. One hundred seventy uninfected and 10 infected subjects were included in the study. Nine of the 10 infected patients had an elevated WBC (>10.4 × 103/μL), with a significantly greater WBC (15.9 × 103/μL) than the uninfected group (10.4 × 103/μL) (p-value ≤ 0.0001). Using logistic regression, we found no association between patient vital signs and CSF infection except for WBC (p = .003). As a diagnostic marker for CSF infection, the sensitivity and specificity of WBC elevation greater than 15 × 103/μL was 70% (7/10) and 90.2% (147/163), respectively. This study serves as a ‘proof of concept’ that WBC could be useful as potential screening tool for early detection of CSF infection post-EVD placement. Future investigation using a large, multicenter prospective study is needed to further assess the applicability of this parameter.

Infected External Ventricular Drainage After Ruptured Intracranial Aneurysm: Clipping Time Challenge

Background: Ventriculostomy-Related Infections (VRIs) are reported in 3%–29% of patients with Subarachnoid Hemorrhage (SAH), and is strongly associated with the placement of Cerebrospinal Fluid (CSF) catheters. Considering the risk of placement of a metal clip in an infected environment, the timing of clipping in these patients is a challenging issue. Objectives: To treat the patients with a ruptured aneurysm that simultaneously had infection induced by External Ventricular Drainage (EVD). Materials &amp; Methods: This study was carried out from January 2016 to December 2018 in an academic hospital in the north of Iran. A total of 42 consecutive patients with spontaneous SAH treated with EVD were enrolled in this study. The results of laboratory tests of CSF (proven or suspected ventriculitis) and timing from ictus to aneurysm surgical clipping, length of VRIs, and patients’ outcomes were reviewed. Analysis of the obtained data was performed by ANOVA, Fisher exact test and the Chi-square test in SPSS 20. P values less than 0.05 were considered significant. Results: Among non-infected patients, the best time of clipping is less than 3 days that resulted in the least complications (P=0.047). Among the infected patients, the rate of death in patients undergone surgery 4-14 days later was more than the patients undergone surgery after 2 weeks and the rate of severe complications was even more after 2 weeks. Conclusion: If there is simultaneous brain aneurysm and infection induced by EVD, aneurysm clipping is better to be done in less than 3 day that reduces the vasospasm too, otherwise the clipping is better to be done after treatment of the infection i.e. 2-3 weeks later.

Natural history of ventriculostomy-related infection under appropriate treatment and risk factors of poor outcome: a retrospective study.

The authors aimed to describe the natural history of ventriculostomy-related infections (VRIs) under appropriate treatment and to assess risk factors for poor outcome. All patients older than 18 years in whom an external ventricular drain (EVD) had been implanted and who had developed a VRI requiring treatment were included in this retrospective study. D0 was defined as the first day of antibiotic administration. Clinical and biological parameters were compared each day beginning with D1 and ending with D10 to those of D0. The authors defined D0 in a control group as the day a CSF culture came back positive, without any sign of infection. The authors then searched for poor prognostic factors in the VRI group. Among 567 patients requiring an EVD between January 2007 and October 2017, 39 developed a VRI. Most were monomicrobial infections, and 47 microbes were responsible (45% were gram-positive cocci). Clinical parameters differed significantly from the control group during the first 2 days and then returned to baseline. The CSF parameters differed significantly from the control group for a longer period, returning to baseline after 5 days. CSF sterilization occurred in a median time of 2 days. An intrathecal route or EVD exchange was not associated with a poor outcome. No clinical or biological parameter between D3 and D5 was linked to outcome. Clinical status improved faster than CSF parameters (before and after D5, respectively). Some CSF parameters remained abnormal until D10. Body temperature and microbiological cultures normalized faster than other parameters.

Diagnosis of ventriculostomy-related infection: Is cerebrospinal fluid lactate measurement a useful tool?

ObjectiveTo evaluate the value of CSF lactate (LCSF) for the diagnosis of ventriculostomy related infections (VRI), and compare it with other CSF markers. MethodsProspective study of neurocritical patients admitted to Maciel Hospital and Clinicas Hospital ICUs in which an external ventricular drain (EVD) was inserted. In patients with clinical suspicion of VRI, a CSF sample was obtained through the EVD for CSF culture and markers analysis (glucose, protein, lactate and leukocytes). We defined proven VRI according to preset criteria as: fever, plus CSF alterations (glucose <50mg/dl or leukocytes >500/μl), plus positive CSF culture. CSF markers were plotted in a receiver operating curve (ROC) to evaluate their diagnostic accuracy. Results36 CSF samples were obtained: 14 corresponded to proven VRI and 22 to excluded VRI. Median LCSF was 9.90mmol/L (IQR: 4.7–12) for proven VRI versus 2.95mmol/L (IQR: 2.4–3.6) for excluded VRI (p<0.001). Both LCSF and CSF glucose showed a good diagnostic accuracy for VRI, with an AUC of 0.900 and 0.951 respectively. We found the following diagnostic values for LCSF: sensitivity of 86%, specificity of 86%, PPV of 80%, NPV of 91%, cut-off value of 4mM, positive likehood ratio of 6.1, negative likehood ratio of 0.16, Youden Index of 0.72 and Diagnostic Odds Ratio of 34. ConclusionsFor the studied population, LCSF represents a good marker for VRI. It could be used as a quick and specific test to identify the need for antimicrobial therapy in patients with clinical suspicion of VRI.

Impact of dexamethasone in patients with aneurysmal subarachnoid haemorrhage.

The role of corticosteroids in the treatment of patients with aneurysmal subarachnoid haemorrhage (SAH) has remained controversial for decades. Recent studies have suggested that the administration of corticosteroids in SAH patients is associated with favourable outcomes. Given their significant adverse effects, it is essential to identify those patients who will benefit from treatment with corticosteroids. A retrospective analysis of a prospectively collected cohort (n = 306) with SAH who were treated by microsurgical clipping or endovascular intervention was performed. The role of dexamethasone administration was analysed with regard to clinical conditions and SAH-related complications. Outcome was assessed at discharge and during follow-up using the Glasgow Outcome Scale (GOS). Patients treated with dexamethasone presented with more episodes of hyperglycaemia (P < 0.001), more overall infections (P < 0.001) and more ventriculostomy-related infections (P = 0.004). Multivariate analysis demonstrated that treatment with dexamethasone was associated with an unfavourable outcome at discharge (GOS 1-3) [odds ratio (OR) 2.814, 95% confidence interval (CI) 1.440-5.497, P = 0.002]. In the subgroup of microsurgically treated patients, dexamethasone administration was associated with a favourable outcome at follow-up (OR 0.193, 95% CI 0.06-0.621, P = 0.006). A higher risk for unfavourable outcome (OR 3.382, 95% CI 1.67-6.849, P = 0.001) at discharge was observed in endovascularly treated patients who received dexamethasone but this had no impact on the outcome at follow-up. Treatment with dexamethasone seems to be associated with a risk reduction for an unfavourable outcome in those patients who underwent microsurgical clipping. Despite an increased frequency of adverse effects, glucocorticoids may have a potential benefit in this specific surgical subgroup compared to endovascularly treated SAH patients.

Ventriculostomy-related infections in subarachnoid hemorrhage patients\u2014a retrospective study of incidence, etiology, and antimicrobial therapy

BackgroundThis study was performed to investigate the incidence and etiology of ventriculostomy-related infections (VRIs) in patients with subarachnoid hemorrhage (SAH) and to assess adherence to local clinical guidelines regarding empirical antimicrobial therapy and diagnostic routines.MethodsA total of 191 consecutive SAH patients treated in the neuro-intensive care unit of Uppsala University Hospital between 2010 and 2013 were included retrospectively. Information regarding cerebrospinal fluid samples, bacterial cultures, ventriculostomy treatment, patient characteristics, and antibiotic treatment were collected from electronic patient records.ResultsEleven patients developed VRI, resulting in an incidence of 5.8% per patient, 5.4% per ventriculostomy catheter, and 4.1 per 1000 catheter days. Coagulase-negative staphylococci caused nine cases of VRI and Klebsiella pneumoniae and Staphylococcus aureus caused one each. Empirical VRI therapy was initiated on 97 occasions in 81 subjects (42.4%). Out of the 11 patients with VRI, four did not receive empirical antibiotic therapy before the positive culture result. The clinical actions performed after analysis of CSF samples were in line with the action suggested by the local guidelines in 307 out of 592 cases (51.9%).ConclusionsThe incidence of VRI in our cohort was comparable to what has previously been reported. Coagulase-negative staphylococci was the most common agent. Our study demonstrates the difficulty in diagnosing VRI in SAH patients. Improved adherence to clinical guidelines could to some extent reduce the use of empirical antibiotic treatment, but better diagnostic methods and routines are needed.

Variations in Strategies to Prevent Ventriculostomy-Related Infections: A Practice Survey.

The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.

Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care.

External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.