Background: Hospital-acquired infections (HAIs) are profound causes of prolonged hospital stay and worse patient outcomes. HAIs pose serious risks, particularly in neurosurgical patients in the intensive care unit, as these patients are seldom able to express symptoms of infection, with only elevated temperatures as the initial symptom. Data from Center for Disease Control (CDC) and the Infectious Disease Society of America (IDSA) have shown that of all HAIs, urinary tract infections (UTIs) have been grossly over-reported, resulting in excessive and unnecessary antibiotic usage.Methods: We conducted a retrospective analysis of 686 adult patients that were evaluated by the neurosurgery service at Arrowhead Regional Medical Center between July 2018 and March 2019. Inclusion criteria were adults greater than 18 years of age with neurosurgical pathology requiring a minimum of one full day admission to the intensive care unit (ICU), and an indwelling urinary catheter. Exclusion criteria were patients under the age of 18, those who did not spend any time in the ICU, or with renal pathologies such as renal failure.Results: We reviewed 686 patients from the neurosurgical census. In total, 146 adult patients with indwelling urinary catheters were selected into the statistical analysis. Most individuals spent an average of 8.91 ± 9.70 days in the ICU and had an indwelling catheter for approximately 8.14 ± 7.95 days. Forty-two out of the 146 individuals were found to have a temperature of 100.4°F or higher. Majority of the patients with an elevated temperature had an infectious source other than urine, such as sputum (22 out of 42, 52.38%), blood (three out of 42, 7.14%) or CSF (one out of 42, 2.38%). We were able to find only two individuals (4.76%) with a positive urine culture and no evidence of other positive cultures or deep vein thrombosis.Conclusions: Our analysis shows evidence to support the newest IDSA guidelines that patients with elevated temperatures should have a clinical workup of all alternative etiologies prior to testing for a urinary source unless the clinical suspicion is high. This will help reduce the rate of unnecessary urine cultures, the over-diagnosis of asymptomatic bacteriuria, and the overuse of antibiotics. Based on our current findings, all potential sources of fever should be ruled out prior to obtaining urinalysis, and catheters should be removed as soon as they are not needed. Urinalysis with reflex to urine culture should be reserved for those cases where there remains a high index of clinical suspicion for a urinary source.

Spontaneous intracranial hypotension (SIH) is a pathology characterized by orthostatic headaches, diffuse pachymeningeal enhancement on magnetic resonance imaging (MRI), and low to normal cerebrospinal fluid (CSF) pressures.We present the case of a 46-year-old male with refractory postural headaches, found to have a diffuse CSF leak throughout the cervicothoracic (C1-T12) spine. His neurological status declined rapidly to a Glasgow Coma Scale (GCS) of eight, necessitating bilateral subdural drain placement. Despite an overall brisk neurologic recovery, the patient remained unable to speak for nearly a week after the return of the remainder of his function. This raised the concern for possible cerebellar mutism.We review the multiple modalities used in this patient's treatment and explore possible explanations for the failure of initial therapy. The placement of bilateral subdural drains was a temporizing measure to treat the patient's neurologic decline, but it was likely the epidural blood patch with prolonged bedrest that hastened the patient's recovery. His speech function also returned with time and repeated therapy.

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Collet-Sicard syndrome is a unilateral palsy of the lower cranial nerves IX, X, XI, and XII, resulting from lesions at the skull base that affect the jugular foramen and hypoglossal canal. Common causes of the lesions include basilar skull fractures, carotid artery dissections, and malignancy. Infectious and inflammatory etiologies have also been reported. A 63-year-old male with a history of uncontrolled diabetes was admitted for dysphagia, right ear pain, drainage, and right-sided facial droop after recent local trauma and surgical instrumentation of the right ear. Culture of the external auditory canal grew Pseudomonas aeruginosa. Triple phase bone scan demonstrated osteomyelitis at the skull base due to complications from otitis externa. The patient's presentation was consistent with Collet-Sicard syndrome, and he was subsequently treated with a six-week course of ciprofloxacin. This patient demonstrates a unique case since his malignant otitis externa spread locally and led to skull base osteomyelitis and subsequently developed Collet-Sicard syndrome. His uncontrolled diabetes likely played a role in his disease progression.