Predictors of ventriculostomy infection in a large single-center cohort

Ventriculitis due to multidrug-resistant gram-negative bacilli associated with external ventricular drain: evolution, treatment, and outcomes

Introduction

Nosocomial infectious ventriculitis caused by multidrug-resistant (MDR) Gram-negative bacilli associated with external ventricular drainage (EVD) placement poses a significant mortality burden and hospital costs.

Objectives

This study aims to analyze the characteristics, ventriculitis evolution, treatment, and outcomes of patients with ventriculitis due to MDR Gram-negative bacilli associated with EVD placement.

Methods

A retrospective cohort study focusing on patients with nosocomial infection caused by MDR Gram-negative bacilli while on EVD was conducted from 2019 to 2022. Medical, laboratory, and microbiological records were collected. The antibiotic resistance of the Gram-negative bacilli isolated in the cerebrospinal fluid (CSF) of patients was analyzed. The risk factors were identified using univariate risk models and were analyzed using survival curves (Cox regression). An adjusted Cox proportional hazards model was also constructed.

Results

Among 530 patients with suspected EVD-associated ventriculitis, 64 patients with isolation of Gram-negative bacilli in CSF were included. The estimated mortality was 78.12%. Hemorrhages (intracranial, subarachnoid, and intraventricular) were observed in 69.8% of patients. Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most frequently isolated bacilli. In the univariate analysis, significant risk factors for mortality included arterial hypertension, a Glasgow Coma Scale (GCS) score of ≤ 8, invasive mechanical ventilation (IMV) upon hospital admission and during hospitalization, septic shock, and ineffective treatment. The adjusted Cox proportional hazards model revealed that septic shock (HR = 3.3, 95% CI = 1.5-7.2; p = 0.003) and ineffective treatment (HR = 3.2, 1.6-6.5, 0.001) were significant predictors. A high resistance to carbapenems was found for A. baumannii (91.3%) and P. aeruginosa (80.0%). Low resistance to colistin was found for A. baumannii (4.8%) and P. aeruginosa (12.5%).

Conclusion

Ineffective treatment was an independent hazard factor for death in patients with ventriculitis caused by MDR Gram-negative bacilli associated with EVD.

Risk, Predictive, and Preventive Factors for Noninfectious Ventriculitis and External Ventricular Drain Infection

BACKGROUND

External ventricular drain (EVD) is used for monitoring intracranial pressure or diverting cerebrospinal fluid. However, confirmation of an infection is not immediate and requires obtaining culture results, often leading to the excessive use of antibiotics. This study aimed to compare noninfectious ventriculitis and EVD infection in terms of the risk factors, predictors, prognosis, and effectiveness of care bundle interventions.

METHODS

This retrospective study was conducted at a medical center with 1,006 beds in northern Taiwan between January 2018 and July 2022. Standard EVD insertion protocols and care bundles have been implemented since 2018, along with the initiation of chlorhexidine.

RESULTS

In total, 742 EVD cases were identified. Noninfectious ventriculitis typically presents with fever approximately 8 days following EVD placement, whereas EVD infection typically manifests as fever after 20 days. Aneurysmal subarachnoid hemorrhage was strongly associated with the development of noninfectious ventriculitis (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.4). Alcoholism (adjusted OR 3.5, 95% CI 1.1-12.3) and arteriovenous malformation (adjusted OR 13.1, 95% CI 2.9-58.2) significantly increased the risk of EVD infection. The EVD infection rate significantly decreased from 3.6% (14 of 446) to 1.0% (3 of 219) (p = 0.03) after the implementation of chlorhexidine gluconate bathing.

CONCLUSIONS

Aneurysmal subarachnoid hemorrhage or fever with neuroinflammation within 2 weeks of EVD placement is indicative of a higher likelihood of noninfectious ventriculitis. Conversely, patients with arteriovenous malformation, alcoholism, or fever with neuroinflammation occurring after more than 3 weeks of EVD placement are more likely to necessitate antibiotic treatment for EVD infection. Chlorhexidine gluconate bathing decreases EVD infection.

Construction and validation of infection risk model for patients with external ventricular drainage: a multicenter retrospective study

PURPOSE

External ventricular drainage (EVD) is a life-saving neurosurgical procedure, of which the most concerning complication is EVD-related infection (ERI). We aimed to construct and validate an ERI risk model and establish a monographic chart.

METHODS

We retrospectively analyzed the adult EVD patients in four medical centers and split the data into a training and a validation set. We selected features via single-factor logistic regression and trained the ERI risk model using multi-factor logistic regression. We further evaluated the model discrimination, calibration, and clinical usefulness, with internal and external validation to assess the reproducibility and generalizability. We finally visualized the model as a nomogram and created an online calculator (dynamic nomogram).

RESULTS

Our research enrolled 439 EVD patients and found 75 cases (17.1%) had ERI. Diabetes, drainage duration, site leakage, and other infections were independent risk factors that we used to fit the ERI risk model. The area under the receiver operating characteristic curve (AUC) and the Brier score of the model were 0.758 and 0.118, and these indicators' values were similar when internally validated. In external validation, the model discrimination had a moderate decline, of which the AUC was 0.720. However, the Brier score was 0.114, suggesting no degradation in overall performance. Spiegelhalter's Z-test indicated that the model had adequate calibration when validated internally or externally (P = 0.464 vs. P = 0.612). The model was transformed into a nomogram with an online calculator built, which is available through the website: https://wang-cdutcm.shinyapps.io/DynNomapp/ .

CONCLUSIONS

The present study developed an infection risk model for EVD patients, which is freely accessible and may serve as a simple decision tool in the clinic.

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.

Treatment of Ventriculitis and Meningitis After Neurosurgery Caused by Carbapenem-Resistant Enterobacteriaceae (CRE): A Challenging Topic

Post-neurosurgical infection is a common complication of neurosurgery, and serious infection can threaten the life of patients. In recent years, the increase in multidrug-resistant bacteria, especially carbapenem-resistant Enterobacteriaceae (CRE), has proved fatal to patients. Although there are a few cases of CRE meningitis and few clinical trials have been carried out, it has attracted increasing attention with the increasing probability of its occurrence, especially considering that there are few successful cases. An increasing number of studies are also looking for the risk factors and clinical symptoms of CRE intracranial infection. In terms of treatment, some new antibiotics are gradually being used in the clinic, but due to the complicated drug-resistant mechanism of CRE and the obstruction of the blood‒brain barrier (BBB), the therapeutic effect is still very poor. In addition, obstructive hydrocephalus and brain abscess caused by CRE meningitis are still important causes of patient death and are also difficult to treat.

Risk Factors Promoting External Ventricular Drain Infections in Adult Neurosurgical Patients at the Intensive Care Unit-A Retrospective Study

Objectives: Multiple risk factors have been described to be related to external ventricular drain (EVD) associated infections, with results varying between studies. Former studies were limited by a non-uniform definition of EVD associated infection, thus complicating a comparison between studies. In this regard, we assessed risk factors promoting EVD associated infections and propose a modified practice-oriented definition of EVD associated infections.

Methods: We performed a retrospective, single-center study on patients who were treated with an EVD, at the neurosurgical intensive care unit (ICU) at a tertiary center between 2008 and 2019. Based on microbiological findings and laboratory results, patients were assigned into an infection and a non-infection group. Patient characteristics and potential risk factors were compared between the two groups (p < 0.05). Receiver operating characteristics (ROC) for significant clinical, serum laboratory and cerebrospinal fluid (CSF) parameters were calculated.

Results: In total, 396 patients treated with an EVD were included into the study with a mean age of 54.3 (range: 18–89) years. EVD associated infections were observed in 32 (8.1%) patients. EVD insertion at another hospital (OR 3.86), and an increased CSF sampling frequency of more than every third day (OR 12.91) were detected as major risk factors for an EVD associated infection. The indication for EVD insertion, surgeon's experience, the setting of EVD insertion (ICU vs. operating room) and the operating time did not show any significant differences between the two groups. Furthermore, ROC analysis showed that clinical, serum laboratory and CSF parameters did not provide specific prediction of EVD associated infections (specificity 44.4%). This explains the high overtreatment rate in our cohort with the majority of our patients who received intrathecal vancomycin (63.3%), having either negative microbiological results (n = 12) or were defined as contaminations (n = 7).

Conclusions: Since clinical parameters and blood analyzes are not very predictive to detect EVD associated infections in neurosurgical patients, sequential but not too frequent microbiological and laboratory analysis of CSF are still necessary. Furthermore, we propose a uniform classification for EVD associated infections to allow comparability between studies and to sensitize the treating physician in determining the right treatment.

Deep Brain Electrode Externalization and Risk of Infection: A Systematic Review and Meta-Analysis

BACKGROUND

When evaluating deep brain stimulation (DBS) for newer indications, patients may benefit from trial stimulation prior to permanent implantation or for investigatory purposes. Although several case series have evaluated infectious complications among DBS patients who underwent trials with external hardware, outcomes have been inconsistent.

OBJECTIVE

To determine whether a period of lead externalization is associated with an increased risk of infection.

METHODS

We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review of all studies that included rates of infection for patients who were externalized prior to DBS implantation. A meta-analysis of proportions was performed to estimate the pooled proportion of infection across studies, and a meta-analysis of relative risks was conducted on those studies that included a control group of nonexternalized patients. Heterogeneity across studies was assessed via I2 index.

RESULTS

Our search retrieved 23 articles, comprising 1354 patients who underwent lead externalization. The pooled proportion of infection was 6.9% (95% CI: 4.7%-9.5%), with a moderate to high level of heterogeneity between studies (I2 = 62.2%; 95% CI: 40.7-75.9; P < .0001). A total of 3 studies, comprising 212 externalized patients, included a control group. Rate of infection in externalized patients was 5.2% as compared to 6.0% in nonexternalized patients. However, meta-analysis was inadequately powered to determine whether there was indeed no difference in infection rate between the groups.

CONCLUSION

The rate of infection in patients with electrode externalization is comparable to that reported in the literature for DBS implantation without a trial period. Future studies are needed before this information can be confidently used in the clinical setting.

Healthcare-associated ventriculitis: current and emerging diagnostic and treatment strategies

Introduction: Healthcare-associated ventriculitis and meningitis occur after neurosurgical procedures, is associated with an adverse outcome in the majority of patients and represent a diagnostic challenge to clinicians. As the cerebrospinal fluid (CSF) culture is the cornerstone of diagnosis, obtaining CSF studies prior to starting antibiotic therapy is key.Areas covered: This review will evaluate the incidence, risk factors, clinical presentation, diagnosis, empirical intravenous antibiotic therapy, adjunctive intrathecal therapy, microbiology, prognosis, and prevention of HCAVM. We highlight the challenges and limitations of the currently available diagnostic methods and definitions and explore novel technologies. Our review included the search for published literature until June 2020.Expert opinion: Despite available preventive measures, HCAVM continues to occur and to be independently associated with significant neurological morbidity and mortality in the majority of patients. The cornerstone of the diagnosis of HCAVM is a positive CSF culture but the microbiological yield is reduced to ~50% with prior antimicrobial therapy. Although the CSF profile is not affected by antibiotic therapy it has a fair diagnostic accuracy. Future research efforts should concentrate in identifying novel diagnostic tools such as polymerase chain reaction (PCR) or metagenomic sequencing.