Intra Ventricular antibiotics: Our experience

Jos Jasper¹, Santosham²

¹HOD, Kauvery Brain and Spine Centre, Kauvery Hospital, Cantonment, Trichy

²Critical Care Specialist, Kauvery Hospital, Cantonment, Trichy

Definition and sign

Meningo-Ventriculitis is an Infection of the meningeal and ventricular space. Meningo Ventriculitis may cause fever, headache, nausea, and change in mental status, meningeal irritation, and seizures.It can occur as part of skull base fractures or as part of iatrogenic procedures.

Etiology

Invasive procedures (such as craniotomy, internalventricular catheters, external ventricular drains (EVD), external lumbar catheters, and lumbar puncture
Open head trauma especially skull base Subarachnoid Haemorrhage
Metastatic infection in patients with bacteraemia.

Incidence Rates of Infections

Clean elective NS – 2 to 8%
External drains – 2 to 22%
EVD 7 to 10 days – Biofilm formation & develop VM
Skull Base Fractures 3 to 12%

Ventriculitis mortality – 12 to 23%

Mortality in Skull base Fracture associated Meningo ventriculitis – 18 to 37%

CDC Surveillance Definition 2024 – Meningo Ventriculitis

An organism(s) identified from cerebrospinal fluid (CSF) by a culture or non-culture based microbiologic testing method may indicate Meningitis , if it presented with any following symptoms or signs of clinical significance.

At least two of the following

Fever (>38.0°C) or headache
Meningeal sign(s)
Cranial nerve sign(s)

At least one of the following

Increased white cells & protein, and decreased glucose in CSF
Organism(s) seen on Gram stain of CSF.
Organism(s) identified from blood
Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for organism.

High Risk of Fulminant Meningitis

Skull base fracture involving posterior ethmoids/ sphenoid sinus / Orbito Naso Ethmoidal complex / pneumocephalus
H/O vomiting/aspiration
Steroids – especially MPS in ONI
Presence of CSF drains.

Clinical Assessment Difficulties

Sedated / unresponsive – impaired clinical assessment.
Fever or increase in acute phase proteins can have several etiologies
Potential foci, infectious or non-infectious, including injury to the thermoregulation center
Shunt associated infections usually cause nonspecific symptoms such as general malaise or low-grade fever
Meningeal irritation is present in less than 50% of patients.

CSF Confounding Factors

CSF altered by intracerebral hemorrhage, immunosuppression, and local inflammatory reactions to blood breakdown products or chemicals after trauma/ neurosurgical interventions (Increased proteins/ Elevated Cells)

In patients with EVD, severe disturbances in the CSF flow / volume / dynamics can limit the value of CSF analysis

Prior or concomitant use of antimicrobials in the ICU further complicates interpretation of the CSF tests.

The Role for Intra Thecal (IT) Therapy

Direct drug instillation
Bypass Blood Brain Barrier
Expected faster action
Faster defervescence
Lower dose
Lesser toxicity

Intra Thecal Drugs and their qualities

Polymyxin B, Colistimethate Sodium, Gentamicin, and Vancomycin

Must be preservative free
Not associated with severe or irreversible toxicity
Better pharmacodynamics
CSF sterility and normalization of CSF parameters achieved faster

Intra Ventricular Antimicrobial Therapy

Healthcare-Associated Ventriculitis and Meningitis

Poor response to systemic antimicrobial therapy alone

Ventricular drain to be clamped for 15–60 min to allow the agent to equilibrate throughout the CSF

Dosages and intervals should be adjusted based on CSF antimicrobial concentrations to 10–20 times the MIC of the causative microorganism, ventricular size, and daily output from the ventricular drain

Results and Discussion

Our Experience

Anterior Skull Base fractures	339
Total NS procedures	4698
Meningitis	72
Intravenous	53
Intra Thecal	19

Breakdown of IT Abs Diagnosis

Trauma	16
Post elective surgery with device	02
Post elective surgery without device	01

Culture Profile

Acinetobacter	7
MDR Acinetobacter	4
Klebsiella	3
MDR Klebsiella	1
E. Coli	1
No growth	3

CSF Picture Fulminant Meningitis

Vitals	08/12/23	09/12/23	14/12/23
Protein	72	219	1563
Sugars	80	97.3	17.9
WBC	10	450	64,625
RBC	4600	12,000	22,500

Fulminant Meningitis

Vitals	01/04/22	04/04/22
Protein	38.7	385
Sugars	92	<4
WBC	0	290
RBC	6300	1450
CSF C/S	No growth	Acinetobacter/Genta, Netil, Tige, Mino

Mortality Rate

2018 to 2020 – 4/7 (57%)

2020 to 2024 – 2/12 (16%)

Initially not aggressive and treatment started late.

Incidence Rates of Infections

Clean elective NS – 2 to 8%
External drains – 2 to 22%
Ventriculitis mortality – 12 to 23%
EVD 7 to 10 days – Biofilm formation and Develop VM
Skull Base Fractures – 3 to 12%
Mortality in Skull base Fracture associated Meningo ventriculitis – 18 to 37%

Intra thecal superior in reducing LOS and decreasing mortality especially in Gram negative Multi Drug Resistant Infections.

Discussion

Since 2020,

Improved clinical surveillance
Any sensorium change/ fever/ irritability is “Meningitis” unless proved otherwise
More CSF analysis
Combined Neurosurgeon/ Neurologist/ Neuro Intensivist rounds “Everyday”
Regular “In touch” with the Microbiologist.

Dr. G. Jos Jasper
HOD, Brain and Spine center

Dr. C. M. Santhosam
Critical Care Specialist

Intra Ventricular antibiotics: Our experience

Intra Ventricular antibiotics: Our experience

Jos Jasper1, Santosham2

Journals

Jos Jasper¹, Santosham²