Ventriculitis.pptx

inflammation of brain parenchyma

1. Ventriculitis Dr. Tim Mutafya Surgery Resident Kamuzu Central Hospital, Malawi

2. Layout Introduction Epidemiology Risk factors Diagnosis Principles of management

3. Introduction Ventriculitis is the inflammation of the ependymal lining of the cerebral ventricles, usually secondary to infection for example meningitis, device-related or a complication of trauma AKA Ependymitis, Ventricular empyema, Pyocephalus, and Pyogenic ventriculitis It is an indolent but lethal infection and a source of persistent infection following meningitis treatment . Early diagnosis is essential for appropriate treatment. It is of particular concern in patients with external ventricular drains (EVDs) or intraventricular shunts.

4. Epidemiology Acceptable shunt infection rate is <5-7% Onset of infection after shunt Early 3-20% ( on average 7%) Over 50% staph infection occur in 2 weeks and 70% < 2mo EVD infection incidence is around 9.5% Source of infection Mainly skin 3% CSF infection(therefore need for CSF analysis pre-op)

5. Risk factors Shunt Young age: waiting for 2 weeks in MMC lowers the risk of infection Length of the procedure Open neural tube defect EVD duration of EVD Site leakage blood in CSF (IVH and SAH) Irrigation and flushing

6. Etiology Early infection Staphylococus epidermidis (coagulase-negative staph): 60–75% of infections(most common) S. Aureus Gram-negative bacilli (GNB): 6–20% (may migrate come from intestinal perforation) In neonates: E. coli and Strep. hemolyticus dominate Late infection (> 6 Mo Post OP) 6% Risk per patient. Almost all are indolent infections of S. epidermidis. seeding of a vascular shunt during an episode of septicemia (probably very rare) colonization from an episode of meningitis

7. Etiology cont.. Fungal infection Candida spp. (majority) Usually children < 1 year(1-7%) Possibly related to the use of prophylactic antibiotics used for ICP monitoring and CSF drainage Nguyen MH, Yu VL.

8. Presentation Non-specific syndrome: fever, N/V, H/A, lethargy, anorexia, irritability Shunt malfunction Erythema and tenderness along shunt tubing Distal infection of ventriculoperitoneal shunts may mimic an acute abdomen Shunt nephritis characterized by proteinuria and hematuria. Neonates apneic episodes anemia Hepatosplenomegaly stiff neck Gram neg. bacteria cause more severe symptoms with intermittent fevers. S. Epidermidis tend to be indolent

9. Approach

10. History and exam for: Meningitis Neck stiffness, seizures, fever GI symptoms Diarrhea, Vomiting Otitis media Ear discharge and erythema Pneumonia SOB, cough, fever URI Runny nose, fever Tonsil-pharyngitis Irritability, check the mouth UTI Irritability, suprapubic tenderness, Viral syndromes Cough, runny nose, diarrhea, fever

11. Labs Bloods FBC + differential < 10K (25%) > 20K (30%) Acute phase reactants: ESR & CRP Blood cultures Urine Proteinuria Hematuria CSF Usually <100k Gram + ≈ 50%(Lower yield S. Epid ) Elevated protein Glucose normal or low Lactate PCR Serum procalcitonin Cultures Gram - ve in 40% Higher yield for > 20K

12. Neonatal cranial USS Increased periventricular echogenicity and irregularity of the ventricular surface. Choroid plexus irregularity E chogenic intraventricular debris and well-delineated intraventricular septations

13. CT usually unhelpful in diagnosing infection. Ependymal enhancement when it occurs is diagnostic of ventriculitis. CT may demonstrate shunt malfunction

14. layering debris in the occipital horns.

15. Role of LP usually NOT recommended! May be hazardous in obstructive hydrocephalus (HCP) with a nonfunctioning shunt. Often does not yield the pathogen even in communicating HCP, especially if the infection is limited to ventriculitis. If positive, may obviate a shunt tap

16. Classification Modified Lozier’s definitions

17.  The new parameter allows the diagnosis of nosocomial VRV in patients with intraventricular hemorrhage at a very early point in time before culture results (P < 0.001) Pfausler B, et al, 2004 May;146(5):477-81.

18. Possible ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms and signs, but NEGATIVE Gram stain & cultures Definitive ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms or signs and a POSITIVE Gram stain & cultures Probable ventriculitis CSF WBC count or CSF: blood glucose ratio MORE abnormal than expected, but NOT an extreme value (CSF WBC count 1000/micro L OR CSF: blood glucose ratio < 0.2) and stable (not progressively worsening) attributable symptoms and signs and POSITIVE Gram stain & cultures

19. Possible ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms and signs, but NEGATIVE Gram stain & cultures Definitive ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms or signs and a POSITIVE Gram stain & cultures Probable ventriculitis CSF WBC count or CSF: blood glucose ratio MORE abnormal than expected, but NOT an extreme value (CSF WBC count 1000/micro L OR CSF: blood glucose ratio < 0.2) and stable (not progressively worsening) attributable symptoms and signs and POSITIVE Gram stain & cultures

20. Possible ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms and signs, but NEGATIVE Gram stain & cultures Definitive ventriculitis Progressive rise in cell index or progressive decrease in CSF: blood glucose ratio or an extreme value for CSF WBC count (> 1000/micro L) OR CSF: blood glucose ratio (< 0.2), with attributable symptoms or signs and a POSITIVE Gram stain & cultures Probable ventriculitis CSF WBC count or CSF: blood glucose ratio MORE abnormal than expected, but NOT an extreme value (CSF WBC count 1000/micro L OR CSF: blood glucose ratio < 0.2) and stable (not progressively worsening) attributable symptoms and signs and POSITIVE Gram stain & cultures

21. colonization Multiple positive CSF cultures and/or Gram stain, with expected CSF cell count and glucose levels with NO attributable symptoms or signs Contamination Isolated positive CSF culture and/or Gram stain, with expected CSF cell count and glucose with NO attributable symptoms or signs.

22. colonization Multiple positive CSF cultures and/or Gram stain, with expected CSF cell count and glucose levels with NO attributable symptoms or signs Contamination Isolated positive CSF culture and/or Gram stain, with expected CSF cell count and glucose with NO attributable symptoms or signs.

23. Management

24. Principles High dose of agents Blood: CSF barrier Some hospital-acquired organisms have higher MICs (minimal inhibitory concentration) for antimicrobials than community-acquired organisms Start empiric antibiotics after sampling Modify treatment agent based on C&S Remove catheter Individualized Duration of treatment Rule of thumb: treat for 2 weeks if the infection was with S. aureus and S. epidermidis, and 3 weeks if it was gram-negative

25. Empiric antibiotics Vancomycin for MRSA coverage + meropenem 2 g q 8h to cover gram-negative pathogens. Intraventricular injection of preservative-free antibiotics may be used in addition to IV therapy. Clamp EVD for one hour after injection Streamline therapy based on culture and sensitivity results

26. Treatment steps

27. Treatment without hardware removal Has a lower success rate than device removal Require protracted treatment for up to 45days Patient Indications Terminally ill Poor anesthetic risk Slit ventricles Signs of secondary peritoneal infection Reduced CSF absorption Peritonitis Vascular system—shunt nephritis Sepsis May benefit from partial shunt reversal

28. Device removal Shunt externalization or removal + antibiotics or antifungal agents For shunt-dependent cases make alternative CSF drainage: EVD Intermittent ventricular taps LPs for communicating HCP Advantages of EVD Easy monitoring of CSF flow Control of ICP Aids in CSF surveillance for clearance of infection Administration of intrathecal treatment

29. Intrathecal antibiotics Indications Failure to respond to systemic antibiotics Resistant organism Choose based on susceptibility Dosage depends on Ventricular size Drain output Concentration of causative microorganism

30. Fungal ventriculitis CSF: elevated WCC and protein, normal glucose Antifungal for 6-8 weeks Remove shunt and place EVD( if shunt dependent

31. When to reimplant Negative CSF cultures and functional parameter Virulence factors Low: normal CSF as early as day 3 abnormal CSF after day 7 High: wait until 7-10days after culture is sterile(??regardless) Period of antibiotics does not indicate the clearing of infection

32. Response monitoring clinical improvement Improved CSF parameters and cultures become negative + clinical improvement Daily CSF cultures & analysis are not recommended unless EVD is in place (not practical here)

33. Primary prevention of ventriculitis Pre-Op antibiotics Tunneling >5cm away from burrhole Use antbx -coated catheters( eg Rifampicin+minocycline ) Both routine catheter changes on day 5 and prolonged antibiotics don’t actually reduce the rate of infection

34. References Greenberg’s handbook of neurosurgery 10 th Ed Nguyen MH, Yu VL. Meningitis caused by Candida species: an emerging problem in neurosurgical patients. Clin Infect Dis. 1995 Aug;21(2):323-7. doi: 10.1093/clinids/21.2.323. PMID: 8562739 . Luque -Paz D, Revest M, Eugène F, Boukthir S, Dejoies L, Tattevin P, Le Reste PJ. Ventriculitis : A Severe Complication of Central Nervous System Infections. Open Forum Infect Dis. 2021 Apr 29;8(6):ofab216. doi : 10.1093/ ofid /ofab216. PMID: 34095339; PMCID: PMC8176394. https ://www.thelancet.com/journals/ebiom/article/PIIS2352-3964%2822%2900115-3/fulltext#