Bundle of Measures for External Cerebral Ventricular Drainage-Associated Ventriculitis*:

Advancements in Non-Invasive Intracranial Pressure Monitoring via Optic Nerve Sheath Diameter Measurement

Intracranial pressure (ICP) monitoring is the mainstay of treatment for patients with brain tumors, hydrocephalus, cerebral edema, and traumatic brain injury (TBI). At present, there are 2 main monitoring methods: non-invasive and invasive. Although invasive monitoring of ICP is the criterion standard, non-invasive approaches based on measurement of optic nerve sheath diameter (ONSD) are becoming increasingly popular because of their simplicity, low cost, and accuracy. Ultrasound (US) measurement of ONSD is especially useful because it allows dynamic evaluation of ICP over the hospital and treatment period in a real-time manner and can be performed bedside for better patient acceptance. This paper reviews the research progress, and highlights the advantages, performance, and results of various ONSD measurement approaches, including US-based ONSD measurement, with regard to its principles, operation method, and clinical applications, as well as ONSD measurement by other techniques such as computed tomography (CT) and magnetic resonance imaging (MRI). New developments, including use of the ONSD/ocular transverse diameter (ETD) index and possible future studies on ONSD-based/assisted therapy and treatment for patients with TBI, stroke, and other conditions that can increase ICP will also be discussed.

Performance of routine surveillance diagnostics of external ventricular drain-associated infections in a critical care setting: a retrospective cohort study

INTRODUCTION

External ventricular drains (EVDs) are crucial for treating neurocritically ill patients but are complicated by feared EVD-associated infections (EVDIs) in up to 35% of all inserted drains, contributing significantly to morbidity, mortality and account for a significant proportion of intensive care unit (ICU) antibiotic use. However, the lack of a universal definition for EVDIs leads to inconsistent diagnostic criteria across studies, with a concern of substantial overtreatment with broad-spectrum antibiotics. This study aimed to evaluate if current EVDI surveillance parameters can be optimized to better distinguish true from suspected EVDI.

METHODS

We conducted a retrospective cohort study at the Karolinska University Hospital ICU, including all patients treated with EVDs between 2006 and 2023, excluding patients with primary central nervous system (CNS) infections. EVDI surveillance included biweekly sampling and cultures from cerebrospinal fluid (CSF). Patients were categorized as no infection (NI), suspected infection (SI), or verified infection (VI) based on culture results and treatment status. We employed classification and regression analyses to identify predictors of VI.

RESULTS

Among 1,828 patients with EVDs, 29.8% were initiated on antibiotic treatment due to suspected infection and 4.1% were found to have culture confirmed infections. The main finding is that current accepted diagnostic parameters cannot distinguish aseptic inflammation from true EVDI. In multivariable logistic analysis the best models exhibited low accuracy, with a pseudo- R 2 of only 0.06. CSF lactate was the most important metric in a univariable setting, however with a cut-off of 8.9 mmol/L it showed low discrimintive ability and limited clinical utility.

CONCLUSIONS

In this study we evaluate current accepted EVDI surveillance methods in, to our knowledge, the largest cohort of paired samples to date. We find that current surveillance parameters cannot distinguish aseptic CNS inflammation from true EVDIs in an ICU setting. This contributes to a significant antibiotic overtreatment, with 25% of our entire cohort being unnecessarily initiated on broad-spectrum antibiotics, a number we expect can be generalized. We identify a large clinical problem with consequences on both a individual and population level, and recommend that future research focus on evaluating new techniques, such as fast bedside sequencing methods.

Post-Surgical Central Nervous System Infections in the Era of Multidrug Antibiotic Resistance in Greece-A Single-Center Experience of a Decade

Post-surgical central nervous system infections (PCNSIs) are a major cause of morbidity, poor functional outcomes and mortality in neurosurgical patients. These infections complicate operations of the CNS or are related to the use of neurosurgical devices or drainage catheters. Gram-negative bacteria, with multiple resistance patterns, are often isolated and these infections are difficult to treat, due to suboptimal antibiotic therapeutic levels in the cerebrospinal fluid (CSF). This is a retrospective study of PCNSIs between 2014 and 2024 in a single center of a tertiary hospital in Thessaloniki, Greece. Out of 2401 neurosurgical procedures, forty-one were complicated by PCNSIs, yielding a total PCNSI prevalence of 1.7%. Thirty-five involved cases with positive CSF culture. The most common interventions were craniotomies for the resection of tumors or other lesions (30.1%). Most cases referred to an EVD infection. Acinetobacter baumannii was the most commonly isolated pathogen (34.1%), followed by coagulase-negative Staphylococcus (22%) and Pseudomonas spp. (14.6%). Colistin and tigecycline were the most prescribed combination regimens. The median time to the first positive CSF culture postoperatively was 11 days (IQR 18 days). Empirical antibiotic treatment was adequate in 26 (63.4%) cases. The mortality rate among these patients was 65.7%. Survivors were significantly younger than non-survivors (p < 0.01) and had a shorter ICU length of stay (p < 0.01). The type of infection, time to infection onset, isolated pathogen, susceptibility to the empirical treatment and Charlson Comorbidity Index did not differ between the two groups. The mortality rate remains high in patients with PCNSIs. An integrated approach including surgical source control, supportive care, combination antimicrobial therapy and subsequent rehabilitation are mandatory to achieve treatment success and neurological convalescence.

Ventriculitis incidence and outcomes in patients with aneurysmal subarachnoid hemorrhage: a prospective observational study

OBJECTIVE

To define the incidence of ventriculostomy-associated infections and their impact on the mortality and functional outcomes of patients with aneurysmal subarachnoid hemorrhage.

METHODS

We prospectively included all consecutive adult aneurysmal subarachnoid hemorrhage patients admitted to the neurological intensive care units of the Instituto Estadual do Cérebro Paulo Niemeyer (Rio de Janeiro, Brazil) and Hospital Cristo Redentor (Rio Grande do Sul, Brazil) who required external ventricular drains from July 2015 to December 2020. Daily clinical and laboratory variables were collected at admission and during the hospital stay. The presence of ventriculostomy-associated infections was evaluated daily, according to the Centers for Disease Control and Prevention and Infectious Diseases Society of America criteria. Hospital and 12-month outcomes were compared between patients with and without ventriculostomy-associated infections via both univariate and multivariate analyses.

RESULTS

Out of the 676 patients screened, 271 received external ventricular drains (40%) and were included in the study. The mean age was 54 years (IQR 46-63), 198 were female (72%), 47% had poor grade status (World Federation of Neurological Surgeons scale 4 and 5), and 75% had modified Fisher 3 or 4. The mean time from admission to external ventricular drain placement was 8.8 days. Ventriculostomy-associated infections developed in 127 patients (47%), and the mean time from external ventricular drain to ventriculostomy-associated infection diagnosis was 4.4 days. Hospital and 12-month mortality rates did not differ between the ventriculostomy-associated infection group and the nonventriculostomy-associated infection group (36% versus 40% and 43% versus 49%, respectively). Poor functional outcomes, defined as modified Rankin scores of 4 to 6, showed no difference between groups at hospital discharge (ventriculostomy-associated infections 75% versus nonventriculostomy-associated infections 73%; p = NS) or at 12 months (ventriculostomy-associated infections 49% versus nonventriculostomy-associated infections 53%; p = NS).

CONCLUSION

Ventriculostomy-associated infections are common complications after aneurysmal subarachnoid hemorrhage. Although it was not associated with hospital mortality or functional outcomes in our cohort, improving diagnostic accuracy and preventive measures is essential for better understanding the long-term impact of one of the most severe infectious complications after aneurysmal subarachnoid hemorrhage.

Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study

BACKGROUND

Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion.

METHODS

We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay.

RESULTS

In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel.

CONCLUSIONS

Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.

Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis

Background and Objectives

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures, but EVD-related infection constitutes a significant health concern. Yet, little consensus identifies the risk factors for the development of EVD-related infection. Therefore, we performed a meta-analysis to systematically summarize existing evidence on the incidence and risk factors for EVD-related infection.

Methods

PubMed, Embase, and the Cochrane Library databases from database inception to February 28, 2022, were searched for all studies investigating the incidence and risk factors for EVD-related infection. Data were assessed by R-4.2.0 software. The meta-analysis was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI).

Results

A total of 48 studies were included. Among the 29 factors analyzed, statistically significant risk factors were subarachnoid hemorrhage(SAH)/intraventricular hemorrhage(IVH) (OR = 1.48, 95% CI = 1.20-1.82, p < 0.001), concomitant systemic infection (OR = 1.90, 95% CI = 1.34-2.70, p < 0.001), other neurosurgical procedures (OR = 1.76, 95% CI = 1.02-3.04, p = 0.041), change of catheter (OR = 5.05, 95% CI = 3.67-6.96, p < 0.001), bilateral EVDs (OR = 2.25, 95% CI = 1.03-4.89, p = 0.041), (cerebrospinal fluid) CSF leak (OR = 3.19, 95% CI = 2.12-4.81, p < 0.001) and duration of EVD >7 days (OR = 4.62, 95% CI = 2.26-9.43, p < 0.001). The use of silver-coated catheters (OR = 0.57, 95% CI = 0.38-0.87, p = 0.008) and antibiotic-impregnated catheters (OR = 0.60, 95% CI = 0.41-0.88, p = 0.009) might help reduce the risk of infection. No significant difference was indicated in studies evaluating factors like diabetes mellitus (OR = 1.25, 95% CI = 0.90-1.75, p = 0.178), steroids used (OR = 1.52, 95% CI = 0.96-2.4, p = 0.074), prophylactic antibiotics(OR = 0.87, 95% CI = 0.66-1.14, p = 0.308).

Discussion

The meta-analysis of various relevant factors in the onset of EVD-related infection in patients submitted to EVD enabled us to establish a more probable profile of the patients who are more likely to develop it during the treatment.

External ventriculostomy-associated infection reduction after updating a care bundle

BACKGROUND

Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017.

RESULTS

From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements.

CONCLUSIONS

A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions

BACKGROUND

External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications.

METHODS

We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed.

RESULTS

There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies.

CONCLUSIONS

In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

The Use of Intraventricular Instillation of Vancomycin to Prevent External Ventricular Drainage Related Infection: A Clinical Prospective Study

BACKGROUND

External ventricular drainage (EVD)-related infection (ERI) represents an important condition with potential high morbidity with significant impact on patient outcomes. Prophylactic systemic antibiotics are routinely administered to patients with EVD, but they do not significantly lower the incidence of ERIs. Intraventricular treatment with vancomycin appeared to be safe and effective, but most reports are case-reports/-series and retrospective studies.

METHODS

A prospective non-randomized case-control study was conducted in a consecutive series of 116 patients treated with EVD insertion. The study includes the group of patients treated with intrathecal vancomycin (Group A, 62 patients) compared with the control group treated with daily intravenous cefazolin (Group B, 54 patients).

RESULTS

No statistically significant differences were found between the 2 groups with regard to the duration of catheterization and occurrence of ERI during hospitalization. EVD was replaced in 16 cases (25.8%) in group A and in 12 cases (22.2%) in the control group B (P 0.67). Three cases (4.8%) of ERI have been found in group A and 5 (9.3%) in the control group (P = 0.34). All reported cases of infection in group A were caused by gram-negative agents; on the opposite, cases of infections in the control group B were caused above all by gram-positive bacteria with a statistical difference (P = 0.03).

CONCLUSIONS

In this first prospective study on this topic, we found that intrathecal Vancomycin administration in EVDs does not reduce the occurrence of ERI compared with intravenous cefazolin prophylaxis, but induces selection of gram-negative bacteria.

Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis

Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.

Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update

The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

Cerebrospinal fluid cell count variability is a major confounding factor in external ventricular drain-associated infection surveillance diagnostics: a prospective observational study

Background

External ventricular drain (EVD)-related infections (EVDIs) are feared complications that are difficult to rapidly and correctly diagnose, which can lead to unnecessary treatment with broad-spectrum antibiotics. No readily available diagnostic parameters have been identified to reliably predict or identify EVDIs. Moreover, intraventricular hemorrhage is common and affect cerebrospinal fluid (CSF) cellularity. The relationship between leukocytes and erythrocytes is often used to identify suspected infection and triggers the use of antibiotics pending results of cultures, which may take days. Cell count based surveillance diagnostics assumes a homogeneous distribution of cells in the CSF. Given the intraventricular sedimentation of erythrocytes on computed tomography scans this assumption may be erroneous and could affect diagnostics.

Aims

To evaluate the consistency of cell counts in serially sampled CSF from EVDs, with and without patient repositioning, to assess the effect on infection diagnostics.

Methods

We performed a prospective single-center study where routine CSF sampling was followed by a second sample after 10 min, allocated around a standard patient repositioning, or not. Changes in absolute and pairwise cell counts and ratios were analyzed, including mixed regression models.

Results

Data from 51 patients and 162 paired samples were analyzed. We observed substantial changes in CSF cellularity as the result of both resampling and repositioning, with repositioning found to be an independent predictor of bidirectional cellular change. Glucose and lactate levels were affected, however clinically non-significant. No positive CSF cultures were seen during the study. Thirty percent (30%) of patients changed suspected EVDI status, as defined by the cell component of local and national guidelines, when resampling after repositioning.

Conclusions

CSF cell counts are not consistent and are affected by patient movement suggesting a heterogeneity in the intraventricular space. The relationship between leukocytes and erythrocytes was less affected than absolute changes. Importantly, cell changes are found to increase with increased cellularity, often leading to changes in suspected EVDI status. Faster and more precise diagnostics are needed, and methods such as emerging next generation sequencing techniques my provide tools to more timely and accurately guide antibiotic treatment.

Trial Registration NCT04736407, Clinicaltrials.gov, retrospectively registered 2nd February 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03715-1.

Gram-Negative Ventriculostomy-Associated Infections Predict Shunt Dependency in Stroke Diagnoses and Other Brain Injuries

BACKGROUND

Several predictors have been studied for shunt dependency after stroke and other brain injuries. However, little is known about the association between ventriculostomy-associated infections (VAIs) and impaired cerebrospinal fluid (CSF) outflow. Moreover, gram-negative (GN) VAIs induce a potent neuroinflammatory process and are clinically challenging to treat.

OBJECTIVE

To assess if GN-VAIs predict ventriculoperitoneal shunt (VPS) dependency.

METHODS

Retrospective analysis of postprocedure infection rates was performed in 586 patients with external ventricle drainage (EVD) placed on site between 2012 and 2018. We collected sex, age, stroke and nonstroke related, location of EVD placement, type of hospital, EVD duration, and EVD exchange.

RESULTS

Among 586 patients requiring an EVD, 55 developed a VAI. Most were caused by gram-positive (GP) pathogens (61.8%). A total of 120 patients required a conversion from EVD to VPS. Patients with VAIs had higher rates of VPS placement (49.09% vs 17.65%, P < .001), whereas patients with GN-VAIs had significantly higher rates of EVD conversion to VPS (77.78% vs 35.29%, P = .012) compared with GP-VAIs. The multivariate analysis showed that GN-VAIs were an independent predictor for shunt dependency (odds ratio = 12.896; 95% CI 3.407-48.82, P < .001). In receiver operating characteristics analysis, those less than 44.5 yr of age and more than 12 d of EVD duration were identified as the best cutoff values to discriminate the development of GN-VAI.

CONCLUSION

Patients who experience a GN VAI are in greater risk of impaired CSF outflow, thus requiring VPS placement.

Effect of a bundle approach on external ventricular drain-related infection

BACKGROUND

Emergency placement of an external ventricular drain (EVD) is one of the most frequently performed neurosurgical procedures. EVD-related infection continues to be a major challenge causing significant morbidity and costs. Bundle approaches have been shown to reduce infection rates; however, they are still not widely used, and observation periods often were rather short.

METHODS

The present study evaluated the effect of a multi-item bundle approach for EVD placement and care on the occurrence of EVD-related infection. A before/after approach was used to compare groups of consecutive patients over 5-year epochs to control for bias and secondary confounding variables.

RESULTS

The number of patients in the group before implementation of the bundle approach was 141 and 208 thereafter. There were no statistical differences in demographic and other variables. While 41/141 patients (29.1%) had an EVD-related infection before, this was the case in only 10/208 patients (4.8%) thereafter (p < 0.0001). The EVD-related infection rate was reduced from 13.7/1000 catheter days to 3.2/1000, and the 50% probability of an EVD-related infection in correlation to the mean duration of EVD placement was significantly lower (p < 0.0001). Routine EVD replacement was not helpful to reduce EVD-related infection. EVD-related infection rates remained low also over the next 8 years after the study was finished.

CONCLUSIONS

The introduction of a multi-item bundle approach for EVD insertion and care resulted in a marked reduction of EVD-related infection. Long observation periods over 5 years and beyond confirm that short-term changes are sustained with continued use of such protocols.

Decreasing External Ventricular Drain Infection Rates in the Neurocritical Care Unit: 12-Year Longitudinal Experience at a Single Institution

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure, and EVD-related infection is a significant complication. We examined the effect of infection control protocol changes on EVD-related infection incidence.

METHODS

Changes in EVD placement protocol and incidence density of infections after implementation of protocol changes in the neurocritical care unit were tracked from 2007 to 2019. EVD infections were defined using a modified U.S. Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definition of meningitis/ventriculitis for patients with EVDs in situ for at least 2 days confirmed by positive culture. Contribution of protocol changes to EVD infection risk was assessed via multivariate regression.

RESULTS

Fifteen major changes in EVD protocol were associated with a reduction in infections from 6.7 to 2.0 per 1000 EVD days (95% confidence interval [CI], 4.1-5.3; P < 0.001). Gram-positive bacterial infection incidence decreased from 4.8 to 1.7 per 1000 EVD days (95% CI, 2.3-3.9; P = 0.00882) and gram-negative infection incidence decreased from 1.9 to 0.5 per 1000 EVD days (95% CI, 0.6-2.3; P = 0.0303). Of all protocol changes since 2007, the largest reduction in incidence was 3.9 infections per 1000 days (95% CI, 0.50-7.30; P = 0.011), associated with combined standardization of reduced EVD sampling frequency, cutaneous antisepsis with alcoholic chlorhexidine before EVD placement, and use of a subcutaneous tunneling technique during EVD insertion.

CONCLUSIONS

The most significant reduction in EVD infections may be achieved through the combination of reducing EVD sampling frequency and standardizing alcoholic chlorhexidine cutaneous antisepsis and subcutaneous tunneling of the EVD catheter.

Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury

Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.

Population pharmacokinetics of vancomycin in patients with external ventricular drain-associated ventriculitis

BACKGROUND

To determine the distribution of vancomycin into the cerebrospinal fluid (CSF) in patients with external ventricular drain (EVD)-associated ventriculitis, the pharmacokinetics of vancomycin were evaluated and covariate relationships explored.

METHODS

For the population pharmacokinetic model patients were recruited in a neurocritical care unit at the University Hospital of Muenster in the period between January 2014 and June 2015. All patients had a clinical evidence of EVD-associated ventriculitis. Population pharmacokinetic analysis of vancomycin was performed using NONMEM.

RESULTS

A total of 184 blood and 133 CSF samples were collected from 29 patients. The final population pharmacokinetic model is a three-compartment model with linear elimination. Creatinine clearance (Cl_Cr ) and CSF-lactate were detected as significant covariates, showing that the total vancomycin plasma clearance (Cl) depends on Cl_Cr and furthermore the clearance (Cl_dif ) between the central and CSF compartment correlates with CSF lactate concentration. Based on the final model, the following values were estimated by NONMEM: Cl = 5.15 L/h, Q (intercompartmental clearance) = 3.31 L/h, Cl_dif  = 0.0031 L/h, V_central  = 42.1 L, V_CSF  = 0.32 L and the value of V_peripheral was fixed to 86.2 L. With the developed pharmacokinetic model, area under the curve (AUC) values as well as CSF trough levels were simulated.

CONCLUSION

Based on our analysis, the dosing of vancomycin should be referred to the degree of inflammation (derived from the CSF lactate concentration) and renal function (derived from Cl_Cr ).

Surveillance of external ventricular drainage-associated meningitis and ventriculitis in German intensive care units

OBJECTIVE

In light of the infection risk associated with external ventricular drainage (EVD), we decided to establish the surveillance of EVD-associated meningitis/ventriculitis in German intensive care units (ICUs) in the framework of the German national nosocomial infection surveillance system (KISS). Here, we present the current reference data and subsequent risk-factor analysis for EVD-associated meningitis/ventriculitis rates.

METHODS

The surveillance method corresponds with the surveillance methods for device-associated infections recommended by the National Healthcare Safety Network (NHSN). All ICUs participating for at least 1 month from 2008 to 2016 in the module ICU-KISS were included in the reference dataset and the multivariate analysis.

RESULTS

Current reference data (2008-2016) are based on input from 157 ICUs. The mean EVD-associated meningitis/ventriculitis rate per 1,000 EVD days was 3.96, with little variation between neurosurgical, surgical, interdisciplinary (hospitals with >400 beds), and neurological ICUs. In total, 893 EVD-associated meningitis/ventriculitis cases and 225,351 EVD days were included in the risk-factor analysis. After multivariate analysis, 2 factors remained significant: (1) stay in an ICU labeled other than neurosurgical, surgical, interdisciplinary (>400 beds), and neurological as a protective factor and (2) EVD utilization rate above the 75th quantile as a risk factor for acquisition of EVD-associated meningitis/ventriculitis.

CONCLUSIONS

EVD-associated meningitis and ventriculitis are frequent complications of care in intensive care patients at risk. A long hospital stay and/or the presence of the EVD puts the patient at high risk for pathogen acquisition with subsequent infection.

Risk Factors of External Ventricular Drainage-Related Infections: A Retrospective Study of 147 Pediatric Post-tumor Resection Patients in a Single Center

Background: External ventricular drainage (EVD) is common after brain surgery. However, the incidence of EVD-related infection (ERI) is still relatively high and can increase morbidity and mortality.

Objective: The objective of this study was to analyze ERI factors in pediatric population post-brain tumor surgery.

Methods: From January 2016 to December 2017, 147 patients <18 years old underwent tumor removal at Beijing Tiantan Hospital and had postoperative EVD. We recorded basic demographic data as well as several risk factors. We then analyzed whether these factors were related to ERI.

Results: Patients with a preoperative ventriculo-peritoneal (V-P) shunt, those with longer operation time, those who received blood transfusion, those with more frequent cerebrospinal fluid (CSF) sampling, and those with longer indwelling time of EVD had higher risks of infection (p < 0.05). Logistic regression analysis confirmed that a preoperative V-P shunt, operative duration, intraoperative blood transfusion, frequency of CSF sampling, and EVD duration were correlated with postoperative ERI (p < 0.05).

Conclusion: EVD should be removed as soon as possible and any unnecessary procedures should be avoided to reduce the infection rate. However, prophylactic treatment should be given in case patients do not meet the indication for EVD removal.

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

OBJECTIVE

The authors aimed to describe the natural history of ventriculostomy-related infections (VRIs) under appropriate treatment and to assess risk factors for poor outcome.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Prevention of surgical site infections after brain surgery: the prehistoric period to the present

In this historical vignette, the authors discuss the prevention of surgical site infections (SSIs) after brain surgery from the prehistoric period to the present. Although the mechanism for infection was not fully understood until the 19th century, records demonstrate that as early as 10,000 bc, practitioners used gold, a biocidal material, for cranioplasties and attempted to approximate wounds by tying a patient's hair across the incision. Written records from the Egyptian and Babylonian period depict the process of soaking head dressings in alcohol, an antibacterial agent. In the Greek and Early Byzantine period, Hippocrates argued against the formation of pus in wounds and continued to champion the use of wine in wound management. In the 16th century, intracranial silver drains were first utilized in an effort to prevent postoperative infections. The turning point of SSI prevention was in 1867, when Joseph Lister illustrated the connection between Louis Pasteur's discovery of the fermentation process and the suppuration of wounds. Today, there are ongoing investigations and debates about the optimal techniques to prevent SSI after brain surgery. Although tremendous progress in the field of SSI prevention since the prehistoric period has been made, SSI continues to affect morbidity and mortality after brain surgery.

Development and evaluation of a craniocerebral model with tactile-realistic feature and intracranial pressure for neurosurgical training

Objective

In this article, a craniocerebral model is introduced for neurosurgical training, which is patient-specific, tactile-realistic, and with adjustable intracranial pressure.

Methods

The patient-specific feature is achieved by modeling from CT scans and magnetic resonance images (MRI). The brain tissue model is built by the hydrogel casting technique, while scalp, skull, vasculature, and lateral ventricles are all-in-one fabricated by three-dimensional (3D) printing. A closed-loop system is integrated to monitor and control the intracranial pressure. 3D measurements, mechanical tests, and simulated external ventricular drain (EVD) placement procedures are conducted on the model.

Results

A neurosurgical training model is completed with high accuracy (mean deviation 0.36 mm). The hydrogel brain tissue has a stiffness more similar to that of a real brain than the common 3D printed materials. The elasticity modulus of hydrogel brain tissue model is E=25.71 kPa, compared with our softest 3D printed material with E=1.14×103 kPa. Ten experienced surgeons rate the tactile realness of the neurosurgical training model at an average point of 4.25 on a scale from 1 (strongly negative) to 5 (strongly positive). The neurosurgical training model is also rated to be realistic in size (4.82), anatomy (4.70), and effective as an aid to improve blind EVD placement skills (4.65).

Conclusions

The neurosurgical training model can provide trainee surgeons with realistic experience in both tactile feedbacks and craniocerebral anatomy, improving their surgical skills.

Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study

OBJECTIVE

Various strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units.

METHODS

Between 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever.

RESULTS

A total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively.

CONCLUSIONS

These findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.

Risk factors for meningitis in neurosurgical patients with cerebrospinal fluid drains: prospective observational cohort study

BACKGROUND

Cerebrospinal fluid (CSF) drainage or intracranial pressure (ICP) monitoring devices are life-saving devices. We examined the risk factors for infections related to them and assessed the effect of an infection control (IC) intervention.

METHODS

A prospective observational study was conducted in the Neurosurgical Department of our hospital between 2014 and 2017. We included all consecutive patients undergoing CSF catheter insertions, including external ventricular drainage (EVD), lumbar drainage (LD), and ICP catheters. An IC intervention was implemented between March and August 2016. We examined risk factors for meningitis or ventriculitis, defined according to Healthcare-associated infections surveillance definitions, on univariate and multivariate analysis.

RESULTS

A total of 232 patients with 437 drains (212 EVDs, 92 LDs, and 133 ICPs) were included. On univariate and multivariate analysis, the infection incidence was 13.7 per 1000 drain days (17.3/1000 before IC intervention, 7.9/1000 during, and 9.2/1000 after the intervention). Most episodes were caused by Gram-negative bacteria, and the most common pathogen was Acinetobacter baumanii. Risk factors for infection per patient included diabetes mellitus (p = 0.017), CSF leak (p = 0.032), drain opening (p = 0.027), and the duration of the drain in days (p = 0.035). Risk factors per catheter included drain opening (p < 0.001), drain days (p = 0.001), and the IC intervention period compared to before the intervention period (p = 0.037). When restricting the analysis to EVDs, drain days (p = 0.001) was the only significant risk factor.

CONCLUSIONS

Strict adherence to IC, shortening drain duration, and avoiding unnecessary opening and manipulation of the drains are crucial to preventing neurosurgical drain infections.

Improving Ventriculostomy Management: Risk and Cost Reduction Through a Multidisciplinary Approach

OBJECTIVE

Infection is a life-threatening complication of ventriculostomy. The purpose of this quality improvement project was to develop a cost-effective, evidence-based intervention to reduce ventriculostomy-associated infection (VAI) rates.

METHODS

In this retrospective study, patients undergoing ventriculostomy insertion between June 2008 and December 2016 were identified, and charts were reviewed. The study period between June 2008 and August 2010 constituted the baseline (phase 1) in which non-antibiotic-coated ventriculostomy catheters were used and cerebrospinal fluid (CSF) sampling was done daily. Then, 2 sequential interventions were implemented. Between September 2010 and January 2013, antibiotic-coated ventriculostomy catheters (AC-Vs) were used (phase 2). Then, between February 2013 and December 2016, the frequency of CSF sampling was minimized to twice a week (phase 3). The rates of VAI and operational costs, or cost incurred for the external ventricular drain catheter, antibiotics, laboratory analysis, and CSF sampling supplies, were compared for each phase.

RESULTS

The average infection rate for phase 1 was 3.3 infections per 1000 device-days. The VAI rates for phases 2 and 3 were 1.6 and 0.8, respectively. The use of AC-Vs and reduced CSF sampling resulted in a VAI rate decrease of 75.8% (P = 0.01). During 2014, there were no VAIs. The intervention produced an estimated $1.02 million in savings for the institution during phase 3. The average projected savings of this intervention was $175 per patient per day and reduced cost by 72%.

CONCLUSIONS

The use of AC-Vs in combination with decreased frequency of CSF sampling was cost saving and resulted in a significant reduction in device-related infections.

Complications of invasive intracranial pressure monitoring devices in neurocritical care

Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement-and misplacement-is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

Toll-like receptor 2, 4 and 9 polymorphisms and their association with ICU-acquired infections in Central Greece

PURPOSE

To test the potential of four common Toll-like receptor (TLR) polymorphisms to predispose to specific intensive care unit (ICU)-acquired infections and affect outcomes in a Greek ICU.

MATERIALS AND METHODS

The incidence of TLR2-Arg753Gln, TLR4-Asp299Gly, TLR4-Thr399Ile and TLR9-T1237C polymorphisms, and their association with ICU-acquired infections and patients' clinical outcomes were prospectively evaluated The examined genetic polymorphisms were assessed by real-time Polymerase-Chain-Reaction (PCR).

RESULTS

During a 15-month period, 224 patients were enrolled and genotyped. The prevalence of genetic polymorphisms for TLR4-Asp299Gly, TLR4-Thr399Ile, mixed TLR4-Asp299Gly/Thr399Ile, TLR9-T1237C and TLR2-Arg753Gln was 14.4%, 14.7%, 11.2%, 24.5% and 2.2%, respectively. TLR4 polymorphisms were associated with increased susceptibility towards specific ICU-acquired infections, i.e. Gram-negative central-nervous-system infections (CNSI), ventilator-associated pneumonia (VAP) and urinary-tract infections (UTI), principally due to multi-drug resistant (MDR) Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumonia, respectively (all P < 0.05). TLR9-T1237C polymorphism was associated with lower incidence and fewer relapses of CNSIs and UTIs when compared to mixed TLR4-Asp299Gly/Thr399Ile polymorphism group (P ≤ 0.039). ICU-stay was significantly prolonged in TLR4 polymorphisms (P ≤ 0.0416).

CONCLUSIONS

Common TLR-signaling polymorphisms might be implicated in the clinical phenotype of ICU-acquired infections in Central Greece. The possible impact of TLR4 polymorphisms on enhanced susceptibility towards Gram-negative MDR-infections in defined critical-disease states warrants further investigation. Trial Registration Clinical Trials.gov identifier: NCT00932243.

Neuroinflammation as a Target for Intervention in Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a sub-type of hemorrhagic stroke associated with the highest rates of mortality and long-term neurological disabilities. Despite the improvement in the management of SAH patients and the reduction in case fatality in the last decades, disability and mortality remain high in this population. Brain injury can occur immediately and in the first days after SAH. This early brain injury can be due to physical effects on the brain such as increased intracranial pressure, herniations, intracerebral, intraventricular hemorrhage, and hydrocephalus. After the first 3 days, angiographic cerebral vasospasm (ACV) is a common neurological complication that in severe cases can lead to delayed cerebral ischemia and cerebral infarction. Consequently, the prevention and treatment of ACV continue to be a major goal. However, most treatments for ACV are vasodilators since ACV is due to arterial vasoconstriction. Other targets also have included those directed at the underlying biochemical mechanisms of brain injury such as inflammation and either independently or as a consequence, cerebral microthrombosis, cortical spreading ischemia, blood–brain barrier breakdown, and cerebral ischemia. Unfortunately, no pharmacologic treatment directed at these processes has yet shown efficacy in SAH. Enteral nimodipine and the endovascular treatment of the culprit aneurysm, remain the only treatment options supported by evidence from randomized clinical trials to improve patients’ outcome. Currently, there is no intervention directly developed and approved to target neuroinflammation after SAH. The goal of this review is to provide an overview on anti-inflammatory drugs tested after aneurysmal SAH.

Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland

OBJECTIVES

External ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk.

METHODS

A prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR.

RESULTS

A total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4-13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12-5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28-17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25-12.38); p<0.01). There was no association between catheter type or tunnelling distance and ERI.

CONCLUSIONS

In the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types.

A flowchart for building evidence-based care bundles in intensive care: based on a systematic review

Purpose

The Institute for Healthcare Improvement is the founder of the care bundled approach and described the methods used on how to develop care bundles. However, other useful methods are published as well. In this systematic review, we identified what different methods were used to design care bundles in intensive care units. The results were used to build a comprehensive flowchart to guide through the care bundle design process.

Data sources

Electronic databases were searched for eligible studies in PubMed, EMBASE and CINAHL from January 2001 to August 2014.

Study selection

There were no restrictions on the types of study design eligible for inclusion. Methodological quality was assessed by using the Downs & Black-checklist or Appraisal of Guidelines, REsearch and Evaluation II.

Data extraction

Data extraction was independently performed by two reviewers.

Results of data synthesis

A total of 4665 records were screened and 18 studies were finally included. The complete process of designing bundles was reported in 33% (6/18). In 50% (9/18), one of the process steps was described. A narrative report was written about care bundles in general in 17% (3/18). We built a comprehensive flowchart to visualize and structure the process of designing care bundles.

Conclusion

We identified useful methods for designing evidence-based care bundles. We built a comprehensive flowchart to provide an overview of the methods used to design care bundles so that others could choose their own applicable method. It guides through all necessary steps in the process of designing care bundles.

Cell Index in the Diagnosis of External Ventricular Drain-Related Infections

BACKGROUND

The use of an external ventricular drain is required for the treatment of many diseases, such as traumatic brain injury and subarachnoid hemorrhage (SAH). Meningitis and ventriculitis are frequent complications arising from the use of external ventricular drain therapy. This study aimed to determine the sensitivity, specificity, and cutoff point for cell index (CI) in patients with traumatic brain injury, SAH, and hemorrhagic stroke.

METHODS

Our study population consisted of patients with different underlying diseases and few culture-positive cerebrospinal fluid samples. The diagnosis of infection was based on Centers of Disease Control and Prevention criteria.

RESULTS

Overall CI analysis showed an area under the curve (AUC) of 0.982. The cutoff of 2.9 for overall CI provided a sensitivity of 95% and a specificity of 92.9%. In patients with SAH, the AUC was 1.0 for a CI of 2.8; furthermore, sensitivity and specificity were 100%. The relative variation of the CI was also assessed. This analysis revealed an AUC of 0.882, and a 4.33-fold increase was found be indicative of infection (P = 0.002), findings similar to those in the literature. In addition, a heatmap analysis demonstrated that the CI is unlikely to return to normal in patients with meningitis, even after treatment.

CONCLUSIONS

Therefore, CI is valuable for the diagnosis of infection, but was inadequate for monitoring treatment. We hope to use the new cutoff point proposed by this study in our institution to improve patient clinical outcome.

Rates of iatrogenic ventriculitis before and after the use of an alcohol-impregnated external ventricular drain port cap

Iatrogenic ventriculitis is a potential complication of ventriculostomy drain placement. In this study, an alcohol-impregnated external ventricular drain port cap was added to a standardized ventriculostomy placement bundle. Rates of ventriculitis were reduced postintervention, but this finding did not reach statistical significance.

External Ventricular Drain-Related Infection in Spontaneous Intracerebral Hemorrhage

OBJECTIVE

We aimed to analyze infection rates in patients with spontaneous intracranial hemorrhage who underwent surgical external ventricular drain (EVD) placement.

METHODS

This prospective study included 94 consecutive patients who required an EVD for spontaneous intracranial hemorrhage at the Neurosurgery Department of Hospital Cristo Redentor, Porto Alegre, Rio Grande do Sul, Brazil.

RESULTS

The mean duration of EVD use was 7 days. Overall sample mortality was 45%, and overall infection rate was 36%. Patients who had an EVD in place >10 days had higher odds of infection than patients who had an EVD in place ≤10 days (odds ratio = 3.1, 95% confidence interval, 1.1-8.7). Culture positivity rate was 5.3%.

CONCLUSIONS

Our findings suggest that EVD infection is a very common complication, occurring in 36.2% of cases. We adopted ventriculitis as the standard diagnosis, as advocated by the U.S. Centers for Disease Control and Prevention. Considering the high lethality associated with intracranial hemorrhage, use of a more aggressive treatment protocol for this patient population might improve morbidity and mortality rates.

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

BACKGROUND AND PURPOSE

The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Colistin and tigecycline for management of external ventricular device-related ventriculitis due to multidrug-resistant Acinetobacter baumannii

Acinetobacter baumannii is an important cause of nosocomial ventriculitis associated with external ventricular device (EVD). It is frequently multidrug resistant (MDR), carries a poor outcome, and is difficult to treat. We report a case of MDR Acinetobacter ventriculitis treated with intravenous and intraventricular colistin together with intravenous tigecycline. The patient developed nephrotoxicity and poor neurological outcome despite microbiological cure. Careful implementation of bundle of measures to minimize EVD-associated ventriculitis is valuable.

Outcomes in meningitis/ventriculitis treated with intravenous or intraventricular plus intravenous colistin

BACKGROUND

The aim of this work is to evaluate the outcome of patients treated with intrathecal colistin for meningitis/ventriculitis.

METHODS

This retrospective case series study included patients presenting with nosocomial meningitis/ventriculitis following neurosurgical interventions and having intravenous (IVC group) or intravenous and intrathecal/intraventricular colistin (ITC group) treatment between 2006 and 2014.

RESULTS

Thirty-four patients presented nosocomial meningitis/ventriculitis; 11 (32.5 %) were included in the IVC group and 23 (67.6 %) in the ITC group. The most frequent isolated bacteria were Acinetobacter baumannii. The mean dose was 170,000 (±400) IU and the duration of intraventricular treatment was 16.0 (±8.3) days. The duration of intravenous treatment was 16.0 (±8.3) days in the ITC group and 15.3 ± 7.6 days in IVC group. Hospital mortality was significantly lower in the ITC group compared with the IVC group (13 vs. 72.7 %, p = 0.001).

CONCLUSIONS

The combination of intravenous plus intraventricular (IV-IVT) colistin therapy may improve outcomes in patients attending with meningitis/ventriculitis due to multi-drug resistance infections.