UNASSIGNED: External ventricular drain (EVD)-related infection (ERI) is a common complication in cranial neurosurgery practice with high mortality. The risk factors associated with ERI are not well studied in low- and middle-income countries (LMIC) like India. Identifying the risk variables is a necessity to design robust evidence-based care bundles for ERI prevention.
UNASSIGNED: This is a single-center prospective cohort study. Patients with and without ERI during the 2-year study period were analyzed along with literature review to identify the risk variables associated with ERI. The Institute for Healthcare Improvement (IHI) comprehensive flowchart was used to develop the concept care bundle for ERI prevention.
UNASSIGNED: A total of 211 EVD were inserted during the study period. 15 ERI (7.1%) were identified based on IDSA criteria, with an average infection rate of 11.12 per 1000 EVD days. Gram negative bacteria (GNB) were the predominant pathogen (12/15, 80%), with Klebsiella pneumoniae (6/15, 40%) being the most common bacteria isolated. In multivariate analysis, the risk variables associated with ERI were use of broad spectrum pre-surgical antimicrobial prophylaxis for long duration, choice of posterior craniometric points for EVD insertion, EVD duration >7 days, EVD leak and surveillance cerebrospinal fluid (CSF) sampling at periodic intervals. Based on the risk variables identified in this study and literature review, a consensus decision on the care elements for the insertion and maintenance phases was chosen for the concept care bundle for ERI prevention.
UNASSIGNED: An evidence-based concept care bundle for ERI prevention is proposed for further multicentric evaluation and validation.
UNASSIGNED: Ponnambath DK, Divakar G, Mamachan J, Biju S, Raja K, Abraham M. Development of an Evidence-based Care Bundle for Prevention of External Ventricular Drain-related Infection: Results of a Single-center Prospective Cohort Study and Literature Review. Indian J Crit Care Med 2024;28(8):760-768.

UNASSIGNED: Ventriculitis, characterized by inflammation of the ventricles in the brain, frequently occurs as a complication of neurosurgical interventions such as the insertion of cerebrospinal fluid (CSF) shunts or external ventricular drains. It can also present as a community-acquired pathology, broadening its clinical significance and complicating diagnosis and treatment. This condition presents significant challenges, primarily due to its association with various medical devices and the predisposing conditions of patients which enhance infection risks.
UNASSIGNED: The review comprehensively explores the etiology, risk factors, diagnostic methodologies, and treatment options for ventriculitis. A thorough literature search was conducted, focusing on recent studies, meta-analyses, and clinical reports that discuss the incidence rates, the effectiveness of different management strategies, and the impact of device-related and community-acquired infections. Particular attention is given to the role of CSF drains and shunts, biofilms, and the prophylactic measures employed in clinical settings to mitigate infection risks.
UNASSIGNED: Despite advances in medical technology and infection control protocols, ventriculitis remains a severe complication in both neurosurgical and community settings. The review highlights the need for continued research into innovative diagnostic tools and more effective infection control strategies.

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Rheumatoid arthritis, an inflammatory rheumatic disease predominantly affecting small limb joints, frequently compromises the cervical spine, resulting in spinal instability and the potential surgical necessity. This may result in severe complications, such as ventriculitis, often associated with a high mortality rate and multidrug-resistant organisms. A major challenge lies in achieving therapeutic antimicrobial concentrations in the central nervous system. The authors present a case of a 65-year-old female, with cervical myelopathy due to severe rheumatoid arthritis. Following surgery, the patient developed ventriculitis caused by an extensively drug-resistant Pseudomonas Aeruginosa. Early diagnosis and prompt treatment played a crucial role in facilitating neurological and cognitive recovery.

Meropenem penetration into the cerebrospinal fluid (CSF) is subject to high interindividual variability resulting in uncertain target attainment in CSF. Recently, several authors recommended administering meropenem as a continuous infusion (CI) to optimize CSF exposure. This study aimed to compare the concentrations and pharmacokinetics of meropenem in CSF after intermittent infusion (II) and CI. This prospective, observational study (NCT04426383) included critically ill patients with external ventricular drains who received either II or CI of meropenem. Meropenem pharmacokinetics in plasma and CSF were characterized using population pharmacokinetic modeling (NONMEM 7.5). The developed model was used to compare the concentration-time profile and probability of target attainment (PTA) between II and CI. A total of 16 patients (8 CI, 8 II; samples: nplasma = 243, nCSF = 263) were recruited, with nine patients (5 CI, 4 II) suffering from cerebral and seven patients from extracerebral infections. A one-compartment model described the plasma concentrations adequately. Meropenem penetration into the CSF (partition coefficient (KP), cCSF/cplasma) was generally low (6.0%), exhibiting substantial between-subject variability (coefficient of variation: 84.0%). There was no correlation between the infusion mode and KP, but interleukin (IL)-6 measured in CSF showed a strong positive correlation with KP (P < 0.001). Dosing simulations revealed no relevant differences in CSF concentrations and PTA in CSF between CI and II. Our study did not demonstrate increased penetration rates or higher concentrations of meropenem in the CSF with CI compared with II.
RESULTS: This study is registered with ClinicalTrials.gov as NCT04426383.

Cerebrospinal fluid shunts are the primary treatment for hydrocephalus. However, prolonged external ventricular drain (EVD) use can lead to central nervous system (CNS) infections such as ventriculitis. In the ICU setting, nosocomial infections with gram-negative, multi-drug resistant (MDR) organisms such as Acinetobacter baumannii (AB) prevail, leading to poor outcomes. AB infections are notably challenging due to their genetic drug resistance. Colistin has been reintroduced for use against gram-negative MDR pathogens but has limitations in CNS penetration when administered intravenously. Therefore, intraventricular (IVT) or intrathecal administration of colistin is recommended to enhance its therapeutic reach within the CNS. We present a case of a 22-year-old male admitted after an electric scooter accident with head trauma and hydrocephalus. A ventriculoperitoneal (VP) shunt was inserted, complicated by a nosocomial neuroinfection. Empiric IV therapy with meropenem and vancomycin was initiated. The VP shunt culture identified AB susceptible only to colistin. Intravenous (IV) colistin was added to meropenem with no significant improvement. The addition of IVT colistin significantly improved the patient\'s neurological condition and reduced inflammatory markers. The patient experienced one myoclonic seizure during IVT colistin treatment, managed with antiepileptics. After multiple unrelated nosocomial complications, the patient was discharged in good condition to rehabilitation. This case suggests that IVT colistin, combined with IV administration, may be preferable over IV colistin alone. Medical staff should be informed about the correct prevention and care of EVD-associated infections.

Meningitis, an infection of the meninges of the central nervous system (CNS), can advance quickly and carries a mortality rate reaching 30% among affected patients. It may become complicated by conditions such as hydrocephalus, ventriculitis, and cerebral abscess. Here, we describe a case of meningitis that was complicated by pyogenic ventriculitis and hydrocephalus in a patient with diffuse large B-cell lymphoma (DLBCL) who underwent chemotherapy and radiotherapy. The patient presented with acute change in mental status and high-grade fever, with few episodes of non-bloody vomiting. Blood culture and cerebrospinal fluid (CSF) culture grew Streptococcus pneumoniae, which was sensitive to ceftriaxone. CT scan of the head showed ventriculomegaly, pansinusitis, and a large left mastoid effusion. MRI of the brain showed layering in ventricles, hydrocephalus, and dural enhancement consistent with pachymeningitis. She was treated with ceftriaxone for 21 days with a meaningful outcome. She was discharged home with near-baseline mental capacity for further physical therapy.

BACKGROUND: Ventriculostomy-related infections (VRIs) are reported in about 10 % of patients with external ventricular drains (EVDs). VRIs are difficult to diagnose due to clinical and laboratory abnormalities caused by the primary neurological injury which led to insertion of the EVD. Polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) may enable more accurate diagnosis of VRI. We performed a prospective cohort study to measure the incidence of VRI as diagnosed by 16S rRNA PCR.
METHODS: Patients admitted to intensive care with a primary diagnosis of subarachnoid haemorrhage (SAH), traumatic brain injury (TBI), or intracerebral haemorrhage (ICH), who required an EVD, were assessed for inclusion in this study. Data were extracted from the electronic medical record, bedside charts, or from a prospectively collected database, the Neuroscience Outcomes in Intensive CarE database (NOICE). 16S rRNA PCR was performed on routinely collected CSF as per laboratory protocol. VRI was also diagnosed based on pre-existing definitions.
RESULTS: 237 CSF samples from 39 patients were enrolled in the study. The mean patient age was 55.7 years, and 56.4 % were female. The most common primary neurological diagnosis was SAH (61.5 %). The incidence of a positive PCR was 2.6 % of patients (1 in 39) and 0.8 % of CSF samples (2 in 237). The incidence of VRI according to pre-published diagnostic criteria was 2.6 % - 41 % of patients and 0.4 % - 17.6 % of CSF samples. 28.2 % of patients were treated for VRI. Pre-published definitions which relied on CSF culture results had higher specificity and lower false positive rates for predicting a PCR result when compared to definitions incorporating non-microbiological markers of VRI. In CSF samples with a negative 16S rRNA PCR, there was a high proportion of non-microbiological markers of infection, and a high incidence of fever on the day the CSF sample was taken.
CONCLUSIONS: The incidence of VRI as defined as a positive PCR was lower than the incidence of VRI according to several published definitions, and lower than the incidence of VRI as defined as treatment by the clinical team. Non-microbiological markers of VRI may be less reliable than a positive CSF culture in diagnosing VRI.

Ventriculitis and nosocomial meningitis caused by carbapenem-resistant Gram-negative and vancomycin-resistant Gram-positive bacteria represent a growing treatment challenge. A case of ventriculitis and bacteremia caused by carbapenem-resistant, KPC-producing Klebsiella pneumoniae and vancomycin-resistant Enterococcus faecium in a young woman with acute leukemia who was successfully treated with meropenem/vaborbactam (MVB), rifampicin, and linezolid is described in this paper. This case report emphasizes the importance of a multidisciplinary strategy, including infectious focus control, for the treatment of device-associated central nervous system (CNS) infections from multidrug-resistant bacteria. Considering the novel resistance patterns, more research on drug penetration into the central nervous system, as well as on the necessity of association therapies, is needed.

The aetiology of chronic aseptic meningitis is difficult to establish. Candida meningitis in particular is often diagnosed late, as cerebrospinal fluid (CSF) work-up and imaging findings are nonspecific. A 35-year-old patient with chronic aseptic meningitis, for which repeated microbiological testing of CSF was unrevealing, was finally diagnosed with Candida albicans (C. albicans) meningitis with cauda equina involvement using metagenomic next-generation sequencing (mNGS). This report highlights the diagnostic challenges and the difficulties of treating shunt-associated fungal meningitis.