IDSA Issues New Guidelines on Brain Infections
IPs can help prevent, detect ventriculitis and meningitis
In new guidelines1 on healthcare-associated ventriculitis and meningitis following surgery, the Infectious Disease Society of America (IDSA) calls for a collaborative approach to prevent and detect complex infections with a high percentage of adverse outcomes for patients.
“It is very important to have a multidisciplinary approach because you need the neurologist, the surgeon, the infectious disease physician,” says Rodrigo Hasbun, MD, MPH, one of the authors of the guidelines and an infectious disease physician at McGovern Medical School at UTHealth in Houston. “Infection preventionists are important because they need to identify and classify patients as infected or not. These infections are challenging. The initial diagnosis can be challenging — cultures can be negative. CSF abnormalities could be due to the neurosurgical procedure or a device. The outcomes are really bad, with 80% having an adverse outcome [if infected]. That includes everything, mortality and neurological sequela.”
Among those sequela is permanent disability because the infections can affect the central nervous system. The complex infections may be linked to placement of devices in the brain, other neurosurgery, and head trauma. For example, patients who have placement of shunts or drains for cerebrospinal fluid can develop inflammation of brain ventricles (ventriculitis) or meningitis infection in the brain or spine. Other devices linked to these infections include pumps for administrating drugs in to the spine for pain or treatment, as well as brain electrostimulation hardware to treat neurological diseases like Parkinson’s.
“These infections may be difficult to diagnose because changes in cerebrospinal fluid parameters are often subtle, making it hard to determine if the abnormalities are related to infection, related to placement of devices, or following neurosurgery,” the IDSA notes in the guidelines. “Many of our recommendations are based on expert opinion because rigorous clinical data are not available, and the likelihood that clinical trials will be conducted to answer some of these questions is low.”
Nevertheless, the IDSA guidance can assist diagnosis of meningitis or ventriculitis, which are healthcare-associated by definition because they generally appear in the aftermath of a surgical intervention.
“They are based on whether patients had any neurosurgical procedure,” Hasbun explains. “A lot of these infections [are linked to] ventricular shunts, devices, a craniotomy, brain tumor resection, or had head trauma with CSF leaks. After some sort of surgical intervention, these patients develop meningitis or ventriculitis. That is completely different from community-acquired infections, where someone comes in with bacterial meningitis without any history of a previous neurological procedure.”
If infection is suspected, IDSA recommends beginning antibiotic therapy — which often includes vancomycin — until culture results reveal the infectious etiology.
Additionally, the guidelines recommend when a device should be removed and replaced. The guidelines also delve into various ways these infections may be prevented, such as using prophylactic antibiotics during placement of the devices, as well as employing “practice bundles,” specific steps neurosurgeons should take when placing shunts and drains.
“There are several studies that have looked at [infection prevention] protocols, and if you implement them there are still going to be some cases that develop this,” Hasbun says. “With antibiotic therapy for 24 hours, antibiotic-impregnated catheters, and [other protocol measures] you will decrease it, but you are not going to eliminate this.”
For example, he cites some previously published interventions that can prevent nosocomial meningitis. “There are a lot of things that can be done before, during, and after surgery,” he says.
REFERENCES
- Tunkel, AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis Clin Infect Dis 2017;64(6): e34-e65. DOI:
https://doi.org/10.1093/cid/ciw861. - Van de Beek D, Drake JM, Tunkel AR. Nosocomial Bacterial Meningitis. N Engl J Med 2010;362:146-54.
In new guidelines1 on healthcare-associated ventriculitis and meningitis following surgery, the Infectious Disease Society of America (IDSA) calls for a collaborative approach to prevent and detect complex infections with a high percentage of adverse outcomes for patients.
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