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Huang TF, Su YK, Su IC, Yeh YK, Liu HW, Kan IH, Lu YC, Chang YP, Lin CM, Tu YK, Tseng CH. Risk, Predictive, and Preventive Factors for Noninfectious Ventriculitis and External Ventricular Drain Infection. Neurocrit Care 2024:10.1007/s12028-023-01925-9. [PMID: 38253924 DOI: 10.1007/s12028-023-01925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Tzu-Fen Huang
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kai Su
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Chang Su
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yun-Kai Yeh
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, Taiwan
| | - Heng-Wei Liu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Hung Kan
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chun Lu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Yu-Pei Chang
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Min Lin
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yong-Kwang Tu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Hua Tseng
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.
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Chen Z, Taubert M, Chen C, Dokos C, Fuhr U, Weig T, Zoller M, Heck S, Dimitriadis K, Terpolilli N, Kinast C, Scharf C, Lier C, Dorn C, Liebchen U. Plasma and Cerebrospinal Fluid Population Pharmacokinetics of Vancomycin in Patients with External Ventricular Drain. Antimicrob Agents Chemother 2023; 67:e0024123. [PMID: 37162349 PMCID: PMC10269048 DOI: 10.1128/aac.00241-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/15/2023] [Indexed: 05/11/2023] Open
Abstract
Vancomycin is a commonly used antibacterial agent in patients with primary central nervous system (CNS) infection. This study aims to examine predictors of vancomycin penetration into cerebrospinal fluid (CSF) in patients with external ventricular drainage and the feasibility of CSF sampling from the distal drainage port for therapeutic drug monitoring. Fourteen adult patients (9 with primary CNS infection) were treated with vancomycin intravenously. The vancomycin concentrations in blood and CSF (from proximal [CSF_P] and distal [CSF_D] drainage ports) were evaluated by population pharmacokinetics. Model-based simulations were conducted to compare various infusion modes. A three-compartment model with first-order elimination best described the vancomycin data. Estimated parameters included clearance (CL, 4.53 L/h), central compartment volume (Vc, 24.0 L), apparent CSF compartment volume (VCSF, 0.445 L), and clearance between central and CSF compartments (QCSF, 0.00322 L/h and 0.00135 L/h for patients with and without primary CNS infection, respectively). Creatinine clearance was a significant covariate on vancomycin CL. CSF protein was the primary covariate to explain the variability of QCSF. There was no detectable difference between the data for sampling from the proximal and the distal port. Intermittent infusion and continuous infusion with a loading dose reached the CSF target concentration faster than continuous infusion only. All infusion schedules reached similar CSF trough concentrations. Beyond adjusting doses according to renal function, starting treatment with a loading dose in patients with primary CSF infection is recommended. Occasionally, very high and possibly toxic doses would be required to achieve adequate CSF concentrations, which calls for more investigation of direct intraventricular administration of vancomycin. (This study has been registered at ClinicalTrials.gov under registration no. NCT04426383).
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Affiliation(s)
- Zhendong Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Chunli Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Heilongjiang Key Laboratory for Animal Disease Control and Pharmaceutical Development, College of Veterinary Medicine, Northeast Agricultural University, Harbin, People’s Republic of China
| | - Charalambos Dokos
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Weig
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Christina Kinast
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Constantin Lier
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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