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

Background: The diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter., Methods: An analytic, observational, cross-sectional study was conducted at the University of the Philippines - Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed., Results: A total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to < 19 years old. There were no patients < 12 months old as they fulfilled at least one exclusion criteria. Forty-nine of them were later confirmed to have HCAVM based on the CDC/NHSN criteria. A CI cut-off of ≥ 1.21 gave a maximum sensitivity of 30.6% and specificity of 86.4%. Receiver operating characteristic area under the curve (AUC-ROC) analysis was 0.585. Subgroup analysis by age showed sensitivity of 52.9% in the pediatric age group and 3.13% in adults. Subgroup analysis by neurologic indication showed sensitivity of 27.6% for ICH and 35.0% for neoplasms. Subsequent AUC-ROC analyses, however, showed that CI failed to adequately diagnose HCAVM in these subgroups., Conclusions: In our population of neurologic patients who underwent EVD insertion, the cell index is not a reliable parameter in the diagnosis of HCAVM., (© 2024. The Author(s).)

A case of neonatal sepsis caused by Edwardsiella tarda , an uncommon pathogen typically associated with aquatic lifeforms, is described. The infant presented in septic shock with seizures and respiratory failure and was found to have meningitis, ventriculitis and a brain abscess requiring drainage. Only a small number of case reports of neonatal E. tarda infection, several with sepsis with poor auditory or neurodevelopmental outcomes or meningitis, have been described in the literature. This case report suggests that E. tarda , while uncommon, can be a cause of serious central nervous system disease in the neonatal population and that an aggressive approach to pursuing and treating complications may lead to improved neurodevelopmental outcomes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Ventriculoperitoneal shunt (VPS) infection is a severe complication. Early diagnosis could help to decrease morbidity and treatment costs. Lactate has been used for the diagnosis of other central nervous system infections. The aim of this study is to determine the usefulness of lactate for the diagnosis of VPS infection., Methodology: Retrospective cohort study. Lactate was measured in patients who consulted with VPS dysfunction between May 2019 and May 2022. Mean were compared according to culture results. A Receiver Operating Characteristic (ROC) curve was performed to determine the appropriate cut-off point., Result: Lactate has a high negative predictive value but a low positive predictive value for the diagnosis of ventriculitis., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest and have received no external funding for this project., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objectives: Nosocomial ventriculitis is a difficult infectious condition to diagnose given that typical cerebral spinal fluid (CSF) parameters, commonly used in the diagnosis of meningitis, lack sensitivity and specificity in nosocomial ventriculitis. Consequently, novel diagnostics are needed to aid in diagnosing this condition. Herein a pilot study using alpha-defensins (α-defensins) to diagnose ventriculitis is discussed., Methods: From May 01, 2022, to December 30, 2022, ten patients with culture-proven external ventricular drain (EVD)-associated ventriculitis and ten patients without EVD-associated ventriculitis had CSF preserved. Levels of α-defensins were compared between the two cohorts with enzyme-linked immunosorbent assay., Results: There was a statistically significant (P ˂0.0001) higher level of CSF α-defensins in the ventriculitis cohort compared to the non-ventriculitis cohort. The levels of α-defensins were not affected by blood in CSF or bacterial virulence. Patients with other infectious conditions had increased levels of α-defensins but these levels were still statistically significantly (P ˂0.001) less than those seen in the ventriculitis cohort., Conclusion: This pilot study shows that α-defensins have promise as a biomarker to aid in the diagnosis of ventriculitis. If larger studies support the findings here, this biomarker can help improve diagnostic accuracy and decrease unwarranted empirical broad-spectrum antibiotic use in suspected EVD-associated ventriculitis., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: External ventricular drain (EVD) associated ventriculitis is a complication of EVD placement associated with significant morbidity and mortality. Gold-standard for EVD associated bacterial ventriculitis diagnosis involves cerebrospinal fluid (CSF) sampling from the EVD with microscopy, culture and sensitivity testing. The ratio of white blood cells to red blood cells has anecdotally been considered a predictive factor in diagnosing EVD associated ventriculitis, however no study has been done demonstrating this., Methods: A retrospective cross-sectional study was designed to assess whether the ratio of CSF white blood cells to red blood cells could be used to diagnose EVD associated ventriculitis. Data was collected for all patients undergoing EVD insertion at a major neurosurgical unit in Sydney, Australia. A receiver operator characteristics (ROC) curve was used to determine if this ratio was useful, and Youden's index was calculated to determine the appropriate cut-off point., Results: This sample of n = 157 consecutive patients a total of 29 patients were diagnosed with ventriculitis. The area under the ROC curve was significant (0.706, P <0.001), and Youden's index demonstrated an appropriate cut-off point was a ratio of 1:106., Discussion: CSF parameters have long been considered predictive of EVD associated ventriculitis. We demonstrated that using a component of routine testing it is possible to accurately predict a ventriculitis diagnosis. As the ratio is used, it enables discrimination in a raised white blood cell count due to local trauma with interventricular bleeding., Conclusion: CSF white blood cell to red blood cell ratio is an appropriate diagnostic test for ventriculitis., (© 2022 Royal Australasian College of Surgeons.)

Listeria monocytogenes is a Gram-positive food-borne pathogen that causes gastrointestinal symptoms and CNS infection in susceptible hosts. Two lineages of Listeria cause the majority of neurolisteriosis in humans. In this report, we discuss a case of a 23-year-old previously healthy woman who presented with acute-onset rapidly progressive altered mental status after eating undercooked meats at a local restaurant. Given her age and lack of comorbidities, bacterial meningitis was suspected, and she was treated with ceftriaxone, vancomycin, and steroids. MRI of the brain was consistent with meningitis and ventriculitis; CSF analysis also suggested bacterial meningitis. Despite mechanical ventilation, pressors, and ventricular drain placement, she quickly decompensated and died 12 hours after arrival. CSF culture later returned positive for Listeria monocytogenes We used whole-genome sequencing and near-source comparison to identify the Listeria subtype that led to her unexpected presentation. The results suggest that her CSF isolate was consistent with a lineage II Listeria serotype, which is known to exhibit greater genetic variation than the more commonly isolated lineage I serotypes. We conclude the discussion with diagnostic and treatment approaches to neurolisteriosis. In susceptible hosts, namely immunocompromised, pregnant, neonatal, or elderly patients, Listeria infection may result in CNS invasion, causing meningoencephalitis and, rarely, ventriculitis and rhombencephalitis. Although neurolisteriosis most commonly affects individuals with known risk factors, CNS infection is nevertheless possible in otherwise healthy young patients. Suspicion should be raised in patients with an exposure history who do not improve with empiric antibiotics., (© 2022 American Academy of Neurology.)

Background: Intracranial pressure waveform morphology reflects compliance, which can be decreased by ventriculitis. We investigated whether morphologic analysis of intracranial pressure dynamics predicts the onset of ventriculitis., Methods: Ventriculitis was defined as culture or Gram stain positive cerebrospinal fluid, warranting treatment. We developed a pipeline to automatically isolate segments of intracranial pressure waveforms from extraventricular catheters, extract dominant pulses, and obtain morphologically similar groupings. We used a previously validated clinician-supervised active learning paradigm to identify metaclusters of triphasic, single-peak, or artifactual peaks. Metacluster distributions were concatenated with temperature and routine blood laboratory values to create feature vectors. A L2-regularized logistic regression classifier was trained to distinguish patients with ventriculitis from matched controls, and the discriminative performance using area under receiver operating characteristic curve with bootstrapping cross-validation was reported., Results: Fifty-eight patients were included for analysis. Twenty-seven patients with ventriculitis from two centers were identified. Thirty-one patients with catheters but without ventriculitis were selected as matched controls based on age, sex, and primary diagnosis. There were 1590 h of segmented data, including 396,130 dominant pulses in patients with ventriculitis and 557,435 pulses in patients without ventriculitis. There were significant differences in metacluster distribution comparing before culture-positivity versus during culture-positivity (p < 0.001) and after culture-positivity (p < 0.001). The classifier demonstrated good discrimination with median area under receiver operating characteristic 0.70 (interquartile range 0.55-0.80). There were 1.5 true alerts (ventriculitis detected) for every false alert., Conclusions: Intracranial pressure waveform morphology analysis can classify ventriculitis without cerebrospinal fluid sampling., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Background: The sensitive and accurate diagnosis of nosocomial meningitis and ventriculitis is still a critical problem. This study was designed to explore the diagnostic value of cerebrospinal fluid heparin-binding protein (HBP) in nosocomial meningitis and ventriculitis in comparison with procalcitonin and lactate., Methods: In this observational study, 323 suspected patients were enrolled, of which 42 participants were excluded because they could not be accurately grouped, 131 subjects who were eventually diagnosed with nosocomial meningitis or ventriculitis and 150 patients in whom infection was ultimately ruled out were included in the final analysis. The main results are expressed as medians (interquartile ranges). The Chi-squared test was used to compare the baseline characteristics. The Mann-Whitney U-test was used for group and subgroup analyses. The area under the receiver operating characteristic curve was calculated to describe the diagnostic accuracy of the biomarkers. Spearman's partial correlation was used to analyze associations between the biomarkers. Statistical significance was set when p value < 0.05., Results: HBP achieved the largest area under the receiver operating characteristic curve, which was 0.99 (95% confidence interval 0.98-1.00) compared with 0.98 (95% confidence interval 0.96-0.99) for lactate and 0.69 (95% confidence interval 0.62-0.75) for procalcitonin. With a cutoff level at 23 ng/mL, HBP achieved a sensitivity of 97%, a specificity of 95%, a positive predictive value of 93% and a negative predictive value of 98%. The levels of HBP presented no significant discrepancy between patients who received previous empiric anti-infective therapy and those who did not (p > 0.05). Higher concentrations of HBP were present in patients with positive microbiological findings (p < 0.05). Levels of HBP positively correlated with polymorphonuclear cell count (Spearman's rho = 0.68, p < 0.01), white blood cell count (Spearman's rho = 0.57, p < 0.01) and lactate (Spearman's rho = 0.34, p < 0.01)., Conclusions: Cerebrospinal fluid heparin-binding protein is a reliable auxiliary diagnostic marker that is preferable over lactate and procalcitonin in identifying nosocomial meningitis and ventriculitis, and it also contributes to solving the diagnostic difficulties caused by empiric antibiotherapy., (© 2022. The Author(s).)

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.

Background: Petrous apicitis (PA) is a serious infection involving the apical portion of the petrous temporal bone. The classic triad of purulent otorrhea, ipsilateral abducens nerve palsy and retroorbital pain is rarely seen due to early detection and widespread use of antibiotics. Medical management is the primary treatment modality with surgery reserved for cases of recalcitrant petrous apex abscess., Methods and Results: We presented a case of PA with previously untreated otitis media. After multidisciplinary evaluation, the patient was initially treated with intravenous antibiotics followed by drainage of the abscess using a combined transmastoid and middle cranial fossa (MCF) approach. The patient recovered well with no recurrence of the infection based on imaging and symptoms., Discussion: While a variety of different surgical approaches can be used in treatment of PA, we recommend the MCF approach in cases where access to the anterior petrous apex may be challenging via transcanal or transmastoid approach.

Background: The diagnosis of healthcare-associated ventriculitis and meningitis (HAVM) is challenging in the ICU setting. Traditional cerebrospinal fluid (CSF) markers and clinical signs of infection fail to diagnose HAVM in the critically ill setting. We sought to determine the diagnostic accuracy of measuring levels of high-mobility group box 1 (HMGB1) protein in cerebrospinal fluid (CSF) for the diagnosis of HAVM., Methods: In this prospective observational cohort study, we enrolled 29 patients with an implanted external ventricular drainage (EVD). We tested the accuracy of CSF-HMGB1 as a diagnostic test for HAVM when compared to standard CSF parameters., Results: HAVM was diagnosed in 11/29 (37.9%) patients. These patients had significantly higher CSF-HMGB1 levels compared to patients without HAVM (median [IQR] 43.39 [83.51] ng/mL vs 6.46 ng/mL [10.94]; P<0.001). CSF-HMGB1 and CSF-glucose were independently related to HAVM, with OR's (95% CI) of 15.43 (15.37 to 15.48, P<0.0001) and 0.31 (0.30 to 0.32, P<0.0001), respectively. The AUC [CI] of CSF-HMGB1 to predict HAVM was 0.83 [0.72 to 0.94]., Conclusions: HMGB1 is an accurate marker of HAVM and it adds incremental diagnostic value when paired with CSF-glucose measurements. Future larger and multicenter studies should assess the incremental diagnostic value of HMGB1 data when used alongside other established CSF markers of infection, and the external validity of these preliminary results.

Objective: This study aimed to examine whether changes in intracranial pressure (ICP) waveform morphologies can be used as a biomarker for early detection of ventriculitis., Methods: Consecutive patients (N = 1653) were prospectively enrolled in a hemorrhage outcomes study from 2006 to 2018. Of these, 435 patients (26%) required external ventricular drains (EVDs) and 76 (17.5% of those with EVDs) had ventriculitis treated with antibiotics. Nineteen patients (25% of those with ventriculitis) showed culture-positive cerebrospinal fluid (CSF) and were included in the present analysis. CSF was routinely cultured three times per week and additionally if infection was suspected. EVDs were left open for drainage, with ICP assessed hourly by clamping. Using wavelet analysis, we extracted uninterrupted segments of ICP waveforms. We extracted dominant pulses from continuous high-resolution data, using morphological clustering analysis of intracranial pressure (MOCAIP). Then we applied k-means clustering, using the dynamic time warping distance to obtain morphologically similar groupings. Finally, metaclusters and further-split clusters (when equipoise existed) were categorized for broad comparison by clinician consensus., Results: We extracted 275,911 dominant pulses from 459.9 h of EVD data. Of these, 112,898 pulses (40.9%) occurred before culture positivity, 41,300 pulses (15.0%) occurred during culture positivity, and 121,713 pulses (44.1%) occurred after it. K-means identified 20 clusters, which were further grouped into metaclusters: tri-/biphasic, single-peak, and artifactual waveforms. Prior to ventriculitis, 61.8% of dominant pulses were tri-/biphasic; this percentage reduced to 22.6% during ventriculitis and 28.4% after it (p < 0.0001). One day before the first positive cultures were collected, the distribution of metaclusters changed to include more single-peak and artifactual ICP waveforms (p < 0.0001)., Conclusion: The distribution of ICP waveform morphology changes significantly prior to clinical diagnosis of ventriculitis and may be a potential biomarker.

Introduction: Chryseobacterium arthrosphaerae is a gram-negative bacteria, known for its intrinsic multidrug resistance, which can lead to treatment difficulties., Patient Concerns: A 56-year-old male had an indwelling external ventricular drainage catheter for 6 months and had been frequently treated with antibiotics for nosocomial infections. He showed cerebrospinal fluid pleocytosis and an abrupt fever during hospitalization., Diagnosis: He was diagnosed as a ventriculitis caused by Chryseobacterium arthrosphaerae (C arthrosphaerae)., Intervention: Initially, we used ciprofloxacin as the backbone in combination with minocycline (and rifampin). However, fever and pleocytosis persisted, and improvement was slow. We then switched the minocycline and rifampin regiment to trimethoprim/sulfamethoxazole. Following this switch of antibiotics, the patient's pleocytosis rapidly improved, allowing the replacement of his external ventricular drainage catheters. C arthrospharae was no longer growing in cerebrospinal fluid and he was recovered from ventriculitis., Outcomes: The patient remains alive without any incidence of C arthrosphaerae recurrence., Conclusion: We propose trimethoprim/sulfamethoxazole alone or in combination with ciprofloxacin to be good candidates for the treatment of ventriculitis by C arthrosphaerae.

Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.

Background: Patients harboring an external ventricular drain (EVD) who develop signs of infection require screening for infection in the central nervous system (CNS). The cerebrospinal fluid (CSF) can be collected by the EVD or by lumbar puncture (LP). If only one sample is analyzed, the diagnosis might be dubious or false-negative. The objective of this study was to compare the diagnosis accuracy of CNS infection of CSF samples collected from EVD and LP., Methods: We conducted a transversal study where data were prospectively collected from 2016 to 2019. Patients harboring EVD with signs of infection were submitted to the CSF analysis collected by LP and EVD. Diagnosis sensibility and results correlation were analyzed using the kappa index., Results: The 141 samples from LP and 141 samples from EVD were collected from 108 patients. Among the 282 samples, a total of 77 had infection. Seventy CSF samples from LP fulfilled infection criteria. However, only 32 EVD samples demonstrated infection. Among the 70 cases of infection based on the LP sample, 25 CSF samples collected from the EVD were also suggestive of infection; but in 45 patients only the CSF samples from LP met infection criteria. Seven patients had diagnosis of infection only in the EVD sample. The kappa correlation index of the results obtained from LP and EVD was 0.260 and the McNemar χ 2 test was <0.01., Conclusions: The CSF analysis exclusive from the EVD has a low sensibility and negative predictive value. CSF collected from LP has a sensibility 2.18 times higher than EVD., (Copyright © 2020 Elsevier Inc. All rights reserved.)

A 38-year-old male presented to the hospital with headache, fever, and meningeal signs. He had undergone a surgical review of a ventriculoperitoneal shunt system one month earlier. A head computed tomography scan showed hydrocephalus. His medical history included a human immunodeficiency virus infection identified four years before and resolved cryptococcal meningitis, which had necessitated the implantation of the shunt system. Ventricular cerebrospinal fluid (CSF) was obtained, which showed inflammation and, in culture, grew a Gram-negative bacillus identified as multidrug-resistant Klebsiella oxytoca. The shunt was removed and a ventricular drain was installed. Treatment with meropenem and amikacin was established without a response; the CSF white blood cell count continued to increase, with cultures remaining positive. The patient's clinical condition deteriorated to stupor. With informed consent, intraventricular (ITV) treatment with tigecycline was initiated at a dose of 5 mg every 24 h and, three days later, the CSF cultures were negativized. Tigecycline levels in the CSF were quantified by liquid chromatography with ultraviolet detection and showed peak concentrations achieved at two hours after the dose of between 178 and 310 μg/mL. After 11 days of treatment with ITV tigecycline and eight negative CSF cultures, a new CSF shunt was installed. During follow-up review 10 months later, the patient reported he was working. The dose of tigecycline used in this study produced levels 15 to 20 times the minimum inhibitory concentration of the bacteria for up to six hours with adequate tolerance., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To determine the diagnostic value of clinical factors and biochemical or microbiological measures for diagnosing a drain-associated ventriculitis, we summarized the available evidence., Methods: We performed a systematic review and meta-analysis of studies of patients with external ventricular CSF drains who developed drain-associated ventriculitis by searching MEDLINE, EMBASE, and CENTRAL electronic database. We reported the occurrence of abnormal test results in patients with and without drain-associated ventriculitis. For continuous variables, we recalculated mean values presented in multiple studies., Results: We identified 42 articles published between 1984 and 2018 including 3,035 patients with external CSF drains of whom 697 (23%) developed drain-associated bacterial ventriculitis. Indications for drain placement were subarachnoid, intraventricular or cerebral hemorrhage or hemorrhage not further specified (69%), traumatic brain injury (13%), and obstructive hydrocephalus secondary to a brain tumor (10%). Fever was present in 116 of 162 patients with ventriculitis (72%) compared with 80 of 275 (29%) patients without ventriculitis. The CSF cell count was increased for 74 of 80 patients (93%) with bacterial ventriculitis and 30 of 95 patients (32%) without ventriculitis. CSF culture was positive in 125 of 156 episodes classified as ventriculitis (80%), and CSF Gram stain was positive in 44 of 81 patients (54%). In patients with ventriculitis, PCR on ribosomal RNA was positive on 54 of 78 CSF samples (69%)., Conclusion: Clinical factors and biochemical and microbiological measures have limited diagnostic value in differentiating between ventriculitis and sterile inflammation in patients with external CSF drains. Prospective well-designed diagnostic accuracy studies in drain-associated ventriculitis are needed., (© 2019 American Academy of Neurology.)

Objective: The aim of this study was to investigate the diagnostic potential of the inflammatory markers interleukin-6 (IL-6), total leukocyte count (TLC), and protein in the CSF and IL-6, C-reactive protein, and white blood cell count in the serum for the early diagnosis of ventriculitis in patients with traumatic brain injury (TBI) and an external ventricular drain compared with patients without ventriculitis., Methods: Retrospective data from 40 consecutive patients with TBI and an external ventricular drain treated in the authors' intensive care unit between 2013 and 2017 were analyzed. For all markers, arithmetical means and standard deviations, area under the curve (AUC), cutoff values, sensitivity, specificity, positive likelihood ratio (LR), and negative LR were calculated and correlated with presence or absence of ventriculitis., Results: There were 35 patients without ventriculitis and 5 patients with ventriculitis. The mean ± SD IL-6 concentration in CSF was significantly increased, with 6519 ± 4268 pg/mL at onset of ventriculitis compared with 1065 ± 1705 pg/mL in patients without ventriculitis (p = 0.04). Regarding inflammatory markers in CSF, IL-6 showed the highest diagnostic potential for differentiation between the presence and absence of ventriculitis (AUC 0.938, cutoff 4064 pg/mL, sensitivity 100%, specificity 92.3%, positive LR 13, and negative LR 0), followed by TLC (AUC 0.900, cutoff 64.5 /µL, sensitivity 100%, specificity 80%, positive LR 5.0, and negative LR 0) and protein (AUC 0.876, cutoff 31.5 mg/dL, sensitivity 100%, specificity 62.5%, positive LR 2.7, and negative LR 0)., Conclusions: The level of IL-6 in CSF has the highest diagnostic value of all investigated inflammatory markers for detecting ventriculitis in TBI patients at an early stage. In particular, CSF IL-6 levels higher than the threshold of 4064 pg/mL were significantly associated with the probability of ventriculitis.

Multidrug-resistant and extensively drug-resistant Acinetobacter baumannii infections have been increasing as a cause of healthcare-associated infections in the neonatal age group. In this report, we describe a 27-week, 1028 g, preterm neonate with extensively drug-resistant A. baumannii infection complicated by ventriculitis who did not respond to intravenous and intraventricular colistin but did respond after intraventricular tigecycline. This is the first case report describing the use of intraventricular tigecycline in a neonate with ventriculitis.

We report a case of Mycoplasma hominis ventriculitis in a preterm neonate that was successfully identified with 16S ribosomal RNA sequencing and whole genome sequencing after failure to detect the pathogen with conventional diagnostic methods. The infant required doxycycline with subsequent clearance of the infection and no evidence of drug toxicity.

Background: Bacterial ventriculitis is a common complication in children with temporary external ventricular drains (EVD) and the diagnosis is challenging. The present study compared the diagnostic accuracy of novel cerebrospinal fluid (CSF) marker - CD64 expression on neutrophils measured as neutrophil CD64 index (CD64in) to routine laboratory CSF and blood markers for bacterial ventriculitis in children with EVD., Methods: We conducted a prospective, observational study, enrolling children with EVD. CD64in in CSF together with CSF markers (leukocyte count, percentage of neutrophils, glucose, and proteins) and blood markers (leukocyte and differential count, C-reactive protein (CRP), and procalcitonin (PCT)) were studied at the time of suspected bacterial ventriculitis. CD64in was measured by flow cytometry. Diagnostic accuracy determined by the area under the receiver-operating characteristic (ROC) curves (AUC) was defined for each marker., Results: Thirty-three episodes of clinically suspected ventriculitis in twenty-one children were observed during a 26-month period. Episodes were classified into those with microbiologically proven ventriculitis (13 episodes) and into those with microbiologically negative CSF (20 episodes). CD64in and leukocyte count were the only CSF markers that could differentiate between groups with diagnostic accuracy of 0.875 and 0.694, respectively. Among blood markers only CRP and band neutrophils differentiated between groups with diagnostic accuracy of 0.792 and 0.721, respectively., Conclusions: CD64in in CSF is a promising diagnostic marker of bacterial ventriculitis in children with EVD as it has higher diagnostic accuracy than routine blood and CSF markers for diagnosing bacterial ventriculitis at the time of clinical suspicion.

Purpose: Ventriculitis is known to develop after chronic inflammation and bacterial invasion of the ventricular surface with a recurrence of shunt infections. The aim of this study is to evaluate the diagnostic value of elevation in cerebrospinal fluid (CSF) interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) together with CSF culture and laboratory test results in the diagnosis of ventriculoperitoneal (VP) shunt-related ventriculitis, which is known to be more problematic than conventional shunt infection., Methods: The study included a total of 34 patients with a VP shunt due to hydrocephalus, who presented with a headache, fever, and shunt infection at the Emergency Department and had a pre-diagnosis of ventriculitis. Nineteen patients were diagnosed with shunt-related infection or ventriculitis using the CSF obtained from the shunt pump. The IL-1β and TNF-α levels from the CSF samples of all patients were measured using the Micro ELISA immunoassay method., Results: CSF direct microscopic observation revealed that the mean cell count, IL-1β level, CRP level, and blood leukocyte level were higher in patients with ventriculitis compared to those diagnosed with shunt infection (p = 0.02, p = 0.009, p = 0.004, and p = 0.009, respectively). The probability of predicting positive culture outcome was 92.7% with 90.9% sensitivity and 82.6% specificity when IL-1β values exceeded 4.0 pg/ml. TNF-α values did not show a significant, reliable pattern compared to IL-1β., Conclusions: IL-1β is a reliable parameter which shall be used in the diagnosis of ventriculitis by predicting positive culture outcome with high sensitivity and specificity.

Objectives: To evaluate the utility of the corrected CSF white blood cell (WBC) count, cell index, CSF lactate, CSF glucose and a newly developed diagnostic model for the diagnosis of healthcare-associated ventriculitis or meningitis (HCAVM) in the setting of intracranial hemorrhage (ICH)., Patients and Methods: A case-control study of 111 adult patients with ICH with HCAVM (cases) or without HCAVM (controls) matched 1:2 by age, Glasgow Coma Scale (GCS), and Acute Physiology and Chronic Health Evaluation II (APACHE II) score enrolled in a large tertiary care center from 2003 to 2016., Results: Subjects were appropriately matched by age, GCS, and APACHE II score (P > 0.2). Cases had significantly higher CSF WBC count (uncorrected and corrected), cell index, and CSF lactate, but lower CSF glucose levels than controls (P < 0.05). There were no differences between CSF protein, CSF neutrophilic pleocytosis, and serum C-reactive protein between cases and controls (P > 0.1). The diagnostic accuracy as analyzed by the area under the receiver operating characteristic curve (AUC of ROC) was found to be good for the cell index (0.825), fair for the corrected CSF WBC count (0.770), and poor for the diagnostic model and uncorrected CSF WBC count (0.652 and 0.653, respectively)., Conclusion: The diagnosis of HCAVM in patients with ICH remains challenging and although no single parameter is sufficient for diagnosis the cell index proved to be an important indicator of infection in our study., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Ventriculitis after extraventricular drainage is a very important neurosurgical complication in neurocritical care units. It is necessary to make an early diagnosis, given that the morbidity and mortality secondary to it can be variable, and complicate the evolution of neurocritical patients. Despite this, ventriculostomy continues to be an important pillar in monitoring and treatment. Given the urgency of ventriculitis associated with multiresistant germs, new antimicrobial drugs have emerged as part of the treatment, as intraventricular routes have been proposed within the new investigations. However, the foregoing does not yet have sufficient bases to be able to support it. The present review was carried out with the aim of contributing to an early diagnosis and treatment of ventriculitis associated with extra ventricular drainage in neurocritical patients, and in this way to contribute to improve survival and prevent fatal outcomes in these patients., (Copyright: © 2019 Permanyer.)

Infections associated with neurosurgical procedures are serious complications that contribute to the morbidity and mortality of neurocritical patients, as well as to the prolongation of the stay in the ICU and the hospital. The diagnosis is complex since there is no gold standard, so it is based on clinical suspicion, CSF physical-chemical examination, and microbial isolation. Treatment should be initiated early, guided by local epidemiology. The duration will depend on the causative microorganism, its sensitivity and the availability of antibiotic treatments that are effective at the site of infection. The implementation of preventive measures with proven efficacy minimizes the risk of infection. This SADI-SATI intersociety update reviews relevant data recently published on this area at the national at international level regarding epidemiology, diagnostic methodologies, therapeutic approaches, and prevention guidelines.

Background: Defined by an infection of the ventricular system of the brain, ventriculitis is usually known as a health-care associated infection. In contrast, primary pyogenic ventriculitis complicating community-acquired meningitis is uncommon, and mainly described in infants. Only seven cases that have occured in adults have been found in the international literature., Case Presentation: We report here a new case due to Neisseria meningitidis occurring in an 85 year-old-man. The comparison with previous reports allows to drawn several conclusions: (i) cases occurred in relatively old adults (median age: 65 years); (ii) Streptococcus pneumoniae, N. meningitiditis and Staphylococcus aureus are the leading responsible pathogens; (iii) atypical clinical presentation seems the rule in which meningism often lacks; (iv) in absence of clinical or biological specific parameters, modern brain imaging such as magnetic resonance imaging with gadolinium enhancement is of utmost importance for the diagnosis, leading to anticipate an increase of the diagnosis in the near future, thanks to easier access to such exploration; (v) death or serious sequelae commonly occurred; (vi) prolonged antibiotic courses (6 weeks to 3 months) have been used, without strong rational. In the given case, the patient presented with a lack of meningeal irritation signs. The diagnosis was made by MRI considering a lasting confused state. A four-week antibiotic regimen was successful, combining two weeks of intravenous cefotaxime followed by two weeks of oral levofloxacin much easier to administrate and allowing early rehabilitation., Conclusion: Primary bacterial ventriculitis is a real diagnosis challenge. Larger indications of MRI for bacterial meningitis, particularly in cases with an atypical presentation or poor evolution would certainly increase the number of diagnosis.

Infections caused by rare micro-organisms are the subject of research, as researchers are encouraged to find the necessary health measures to prevent and treat the disease, as well as the search for new insights into human-microbial interactions. This report describes the case of a newborn boy diagnosed with hydrocephalus and myelomeningocele who developed ventriculitis and sepsis from resistant Empedobacter brevis. This case highlights the unexpected identification of this bacterium in the cerebrospinal fluid and its multi-resistant pattern, which was crucial for proper therapeutic management. This bacterium shows a mixture of different etiologies in the analysis of cerebrospinal fluid.

Ventriculostomy-associated infections, or ventriculitis, in critically ill patients are associated with considerable morbidity. Efficacious antibiotic dosing for the treatment of these infections may be complicated by altered antibiotic concentrations in the cerebrospinal fluid due to variable meningeal inflammation and antibiotic properties. Therefore, doses used to treat infections with a higher degree of meningeal inflammation (such as meningitis) may often fail to achieve equivalent exposures in patients with ventriculostomy-associated infections such as ventriculitis. This paper aims to review the disease burden, infection rates, and common pathogens associated with ventriculostomy-associated infections. This review also seeks to describe the disease- and drug-related factors that influence antibiotic distribution into cerebrospinal fluid and provide a critical appraisal of current dosing of antibiotics commonly used to treat these types of infections. A Medline search of relevant articles was conducted and used to support a review of cerebrospinal fluid penetration of vancomycin, including critical appraisal of the recent paper by Beach et al. recently published in this journal. We found that in the intensive care unit, ventriculostomy-associated infections are the most common and serious complication of external ventricular drain insertion and often result in prolonged patient stay and increased healthcare costs. Reported infection rates are extremely variable (between 0 and 45%), hindered by the inherent diagnostic difficulty. Both Gram-positive and Gram-negative organisms are associated with such infections and the rise of multi-drug-resistant pathogens means that effective treatment is an ongoing challenge. Disease factors that may need to be considered are reduced meningeal inflammation and the presence of critical illness; drug factors include physiochemical properties, degree of plasma-protein binding, and affinity to active transporter proteins present in the blood-cerebrospinal fluid barrier. The relationship between cerebrospinal fluid antibiotic exposures in the setting of ventriculostomy-associated infection and clinical response has not been fully elucidated for many of the antibiotics commonly used in its treatment. More thorough and clinically relevant investigations are needed to better define blood pharmacokinetic/pharmacodynamics targets and optimal therapeutic exposures for treatment of ventriculostomy-associated infections. It is hoped that this future research will be able to provide clearer recommendations for clinicians frequently faced with dosing-related dilemmas when treating patients with these challenging infections.

BACKGROUND Streptococcus acidominimus, which belongs to the viridans streptococci group, is rarely considered pathogenic in humans. However, over the past 10 years, this bacterium has been reported to cause serious infections in humans, particularly among the critically ill. This article is the first case report of pyogenic ventriculitis (PV) and meningitis caused by S. acidominimus in North America. CASE REPORT A 49-year-old Asian male presented to the emergency department with complaints of a headache, fever greater than 37.8°C (100°F) and confusion, of approximately 3 days duration. He was unable to speak coherently or follow approximately half of the given commands. He appeared ill; an intracranial infection was suspected. Magnetic resonance imaging of the brain showed: 1) infected proteinaceous material and pus-like material throughout the cerebral sulci and in the occipital horns of both lateral ventricles, 2) ependymal signal abnormality of the posterolateral margin of the occipital horn of the left lateral ventricle, and 3) early hydrocephalus suggestive of ventriculitis and meningitis. The blood and cerebrospinal fluid cultures were positive for S. acidominimus. The patient improved with minimal deficits after 6 weeks of IV ceftriaxone without requiring a neurosurgical intervention, such as an intraventricular drain or neuroendoscopic surgery. CONCLUSIONS PV and meningitis caused by S. acidominimus are rare but potentially fatal intracranial infections. Therefore, despite the risk of generalizing, our case report suggests that PV and meningitis caused by S. acidominimus can be effectively treated with a prompt and prolonged course of IV ceftriaxone without neurosurgical intervention.

Background: Iatrogenic ventriculitis is a common complication of the external ventricular drainage. While the procedure and indications for external ventricular drains (EVD) are highly standardized, the treatment of ventriculitis is not clearly defined., Objective: To depict the treatment of iatrogenic ventriculitis currently performed in German hospitals., Methods: A standardized questionnaire consisting of 18 multiple choice questions, each with the ability to provide additional individual answers, covering the diagnosis and treatment of iatrogenic ventriculitis as well as general handling of EVDs, was sent to 121 neurosurgical hospitals registered in the German Society for Neurosurgery (DGNC)., Results: Thirty-three out of 121 hospitals returned the questionnaire. While diagnostics are performed similarly in most hospitals, the treatment varies remarkably. Ten of the 33 (30%) units never applied antibiotics intrathecally and 12 (36%) only in selected (1-20%) cases, while 7 (21%) do this routinely, and the remaining 4 centers vary their treatment. While the targeted systemic therapy after pathogen identification and resistance testing is similar, the choice of empiric antibiotics varies as does the type of drug used for intrathecal therapy. Among the applied systemic antibiotics, vancomycin [n = 23 (70%)] and meropenem [n = 22 (67%)] were the most common, but many others, including ceftriaxone, metronidazol, linezolid, piperacillin/tazobactam, fosfomycin and ceftazidim, are used. There is no standard practice regarding EVD handling. Twelve (36%) hospitals do not replace the EVD after a new diagnosis of ventriculitis, 13 (39%) do so once after the diagnosis, and 8 (24%) regularly switch EVDs after a defined time span (7-20 days), even without signs of infection., Conclusion: Treatment concepts for iatrogenic ventriculitis are very heterogeneous. Thus, there is an urgent need for generating outcome data and defining a standard treatment algorithm with the recently published practice guideline being an important first step.

Streptococcus gallolyticus subsp. pasteurianus, previously recognized as S. bovis biotype II/2, is an uncommon yet important cause of invasive infection in young infants. Here, we report the first case of ventriculitis that was unexpectedly diagnosed in the course of neonatal meningitis due to S. gallolyticus subsp. pasteurianus, and we review the relevant literature. A 28-day-old male infant from Japan presented with fever, lethargy, and irritability. S. bovis was isolated from blood and the cerebrospinal fluid culture and was then identified as S. gallolyticus subsp. pasteurianus. Intravenous antibiotic therapy was initiated, which helped improve the clinical course of the disease; however, the patient presented ventriculitis-related complications diagnosed using follow-up magnetic resonance imaging (MRI) on day 12 of hospitalization. Ampicillin was administered for 21 days and discontinued after the patient showed improvement, according to MRI findings. The patient was discharged without sequelae. Ventriculitis is a rare complication of childhood meningitis due to S. gallolyticus subsp. pasteurianus. However, it may have been underdiagnosed, especially in cases with no specific manifestations similar to the present case. We suggest that MRI should be performed to screen for ventriculitis in the course of meningitis to avoid failure in treatment.

The aim of the study is to explore the experiences in diagnosis and treatment of severe neurosurgical patients with pyogenic ventriculitis caused by gram-negative bacteria (G - ). Nineteen patients with pyogenic ventriculitis were reviewed for their treatment. The bacterial testing results of cerebrospinal fluid (CSF), the clinical intervention, and the patients' prognosis were evaluated. The bacterial smears of ventricular drainage from all the cases were G - bacteria. Head CT and MRI scans confirmed that they were intraventricular empyema. Eighteen cases of CSF bacterial test were positive, including 12 cases of Acinetobacter baumannii positive, 2 of Klebsiella pneumonia positive, 2 of Serratia marcescens positive, 1 of Pseudomonas maltophila positive, and 1 case of Escherichia coli positive. One case of the bacterial culture was negative. All patients were treated by using intraventricular lavage in combination with intravenous and intraventricular antibiotics in accordance with the clinical conditions. After treatment for 2 to 8 weeks, 14 patients were cured (74%) and 5 were died (26%). Eight patients who were cured had received ventriculoperitoneal shunt due to hydrocephalus at 2 to 6 weeks after infection controlled, and none of them had any reinfection. Twelve of the 14 cured cases came to consciousness, but 2 were persistent in vegetative state starting before the infection; they did not show any improving consciousness after infection had been cured. Suppurative ventriculitis in severe neurosurgical patients is mainly infected by G - with a higher mortality. Early diagnosis, especially in identifying pathogen types, timely ventricular irrigation, and ventricular drainage together with intravenous and intraventricular antibiotic treatment, should improve prognosis.

Neurointensive care (NICU) patients experience complex infectious disease challenges. Central nervous system (CNS) infections are difficult to diagnose and treat, and post-neurosurgical patients are vulnerable to a unique set of healthcare-acquired infections (HAI) in addition to those typical of critically ill patients. The purpose of this review is to summarize the approach to suspected infection in the NICU and discuss management of several infectious syndromes in the NICU setting.

Background/objectives: Healthcare-associated meningitis or ventriculitis (HCAMV) is a serious and life-threatening complication of invasive neurosurgical procedures or penetrating head trauma. Older adults are at higher risk of adverse outcomes in community-acquired meningitis but studies of HCAMV are lacking. Therefore, we perform the study to define the differences in clinical outcomes between older and younger adults with HCAMV., Design: Retrospective study., Setting: A large tertiary care hospital in Houston, Texas, from July 2003 to November 2014., Participants: Adults with a diagnosis of HCAMV (N = 160) aged ≥65 (n = 35), aged 18-64 (n = 125)., Measurements: Demographic characteristics, clinical presentation, laboratory results, treatments, and outcomes (Glasgow Outcome Scale)., Results: Older adults had more comorbidities and CSF abnormalities [pleocytosis, high cerebrospinal fluid (CSF) protein, low CSF glucose) and were more likely to have altered mental status than younger adults (P < .05). An adverse clinical outcome was seen in 142 participants (89%) (death (n = 18, 11%), persistent vegetative state (n = 26, 16%), severe disability (n = 68, 43%), moderate disability (n = 30, 19%). There was no difference in adverse outcomes between older (97%) and younger (86%) adults (P = .13). On logistic regression analysis, abnormal neurological examination (adjusted odds ratio (aOR) = 7.13, 95% confidence interval (CI) = 2.15-23.63, P = .001) and mechanical ventilation (aOR = 11.03, 95% CI = 1.35-90.51, P = .02) were associated with adverse clinical outcomes., Conclusion: Older adults with HCAMV have more comorbidities and CSF abnormalities and are more likely to have altered mental status than younger adults but have similar high rates of adverse clinical outcomes., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

OBJECTIVE To evaluate the agreement between the current National Healthcare Safety Network (NHSN) definition for ventriculitis and others found in the literature among patients with an external ventricular drain (EVD) DESIGN Retrospective cohort study from January 2009 to December 2014 SETTING Neurology and neurosurgery intensive care unit of a large tertiary-care center PATIENTS Patients with an EVD were included. Patients with an infection prior to EVD placement or a permanent ventricular shunt were excluded. METHODS We reviewed the charts of patients with positive cerebrospinal fluid (CSF) cultures and/or abnormal CSF results while they had an EVD in place and applied various ventriculitis definitions. RESULTS We identified 48 patients with a total of 52 cases of ventriculitis (41 CSF culture-positive cases and 11 cases based on abnormal CSF test results) using the NHSN definition. The most common organisms causing ventriculitis were gram-positive commensals (79.2%); however, 45% showed growth of only 1 colony on 1 piece of media. Approximately 60% of the ventriculitis cases by the NHSN definition met the Honda criteria, approximately 56% met the Gozal criteria, and 23% met Citerio's definition. Cases defined using Honda versus Gozal definitions had a moderate agreement (κ=0.528; P<.05) whereas comparisons of Honda versus Citerio definitions (κ=0.338; P<.05) and Citerio versus Gozal definitions (κ=0.384; P<.05) had only fair agreements. CONCLUSIONS The agreement between published ventriculostomy-associated infection (VAI) definitions in this cohort was moderate to fair. A VAI surveillance definition that better defines contaminants is needed for more homogenous application of surveillance definitions between institutions and better comparison of rates. Infect Control Hosp Epidemiol 2017;38:574-579.

Introduction: Ventriculitis is a serious infection associated with high mortality even when both intravenous (IV) and intrathecal (IT) antibiotics are administered. Poor outcome in patients with ventriculitis indicates the need to be more aggressive in our attempts to expeditiously eradicate the infection. The purpose of this study was to evaluate the role of endoscopic lavage (EL) in patients with severe purulent ventriculitis, unresponsive to IV and IT antibiotics., Methods: All consecutive patients with severe ventriculitis caused by multidrug-resistant gram-negative bacteria, undergoing EL after failure of prolonged courses of IV and IT antibiotics, were included in the study. The outcome in all these patients was otherwise expected to be uniformly dismal., Results: There were 5 males and 2 females. The age range was one month to 45 years. All patients had frank intraventricular pus. Acinetobacter baumannii was the most common organism grown in cultures. Two patients had multiple bacterial growth in cerebrospinal fluid cultures. The duration of pre-EL IV/IT antibiotics ranged from 3 to 8 weeks. Microbiological cure was achieved in all (7/7) and clinical cure in 86% of patients (6/7). One patient died despite achieving cerebrospinal fluid sterilization 3 months later as a result of progressive white matter edema., Conclusions: The addition of IT antibiotics has resulted in improved outcome in patients with ventriculitis; however, some patients continue to be unresponsive to antibiotics. EL can play a complementary role in eradicating such recalcitrant infections. EL should be considered in any patient with ventriculitis, if infection persists even after ∼7-10 days of IVand IT antibiotics., (Copyright © 2016 Elsevier Inc. All rights reserved.)