Efficacy of periprocedural vs extended use of antibiotics in patients with external ventricular drains – A randomized trial

External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors' view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.

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The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement

Fried

et al. 2016

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Concentrations of Cefuroxime in Brain Tissue of Neurointensive Care Patients

Hosmann

Ritscher

Burgmann

et al. 2018

Antimicrob Agents Chemother

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Effective concentrations of antibiotics in brain tissue are essential for antimicrobial therapy of brain infections. However, data concerning cerebral penetration properties of antibiotics for treatment or prophylaxis of central nervous system infections are rare. Six patients suffering subarachnoid hemorrhage and requiring cerebral microdialysis for neurochemical monitoring were included in this study. Free interstitial concentrations of cefuroxime after intravenous application of 1,500 mg were measured by microdialysis in brain tissue, as well as in plasma at steady-state ( = 6) or after single-dose administration ( = 1). At steady state, free area under the concentration-time curve from 0 to 24 h (AUC) values of 389.0 ± 210.3 mg/liter·h and 131.4 ± 72.8 mg/liter·h were achieved for plasma and brain, respectively, resulting in a brain tissue penetration ratio (AUC/AUC) of 0.33 ± 0.1. Plasma and brain tissue concentrations at individual time points correlated well ( = 0.59, = 0.001). At steady-state time over MIC (>MIC) values of >40% of dosing interval were achieved up to an MIC of 16 mg/liter for plasma and 4 mg/liter for brain tissue. Although MIC values could not be achieved in brain tissue for relevant bacteria, current dosing strategies of cefuroxime might be sufficient to treat pathogens with MIC values up to 4 mg/liter. The activity of cefuroxime in brain tissue might be overestimated when relying exclusively on plasma levels. Although currently insufficient data after single dose administration exist, lower brain-plasma ratios observed after the first dose might warrant a loading dose for treatment and perioperative prophylaxis.

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Risk Assessment and Recommended Approaches to Optimize Infection Control and Antibiotic Stewardship to Reduce External Ventricular Drain Infection: A Single-Center Study

Kelemen,

Sztermen,

Dakos

et al. 2024

Antibiotics

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Background: An external ventricular drain (EVD) is used to release elevated intracranial pressure by draining cerebrospinal fluid (CSF) from the brain’s ventricles. The establishment of an EVD is one of the most commonly performed neurosurgical procedures to treat intracranial pressure in patients. Nevertheless, infections are very frequent complications. Identifying the risk factors for EVD-related infections is a key to improving patient safety and outcomes. Methods: We conducted a retrospective, single-center study of patients who underwent EVD implantation between January 2022 and March 2024. Patients were classified into infected and non-infected groups based on their clinical symptoms, as well as laboratory and microbiological results. Patient characteristics and possible risk factors for infection were compared between the two groups. Results: In total, 123 patients treated with 156 EVDs were included in this study, with a mean age of 55.8 (range: 25–84) years. EVD-associated infections were observed in 37 patients (30%). We found no significant association between infection risk and patient characteristics, including gender, primary diagnosis, craniotomy, or immunosuppression. There was no significant difference in terms of EVD insertion, i.e., whether the insertion took place in the operating room (OR) with antibiotic prophylaxis or outside the OR with no periprocedural antibiotic treatment. However, within the intensive care unit (ICU), EVD infection was much lower (13%) if EVD insertion took place in a single-bed room compared to multiple-bed room insertions (34%). Furthermore, there were significant differences in terms of the duration of first EVD (both single and multiple catheterizations) (p < 0.0001) and the total catheterization time (p = 0.0001). Additionally, there was a significant association with patient days in the ICU and EVD catheterization. Conclusions: Revisiting infection control measures is necessary, with special attention to the replacement of EVDs in single-bed ICU rooms, to introduce antibiotic prophylaxis in the ICU. Minimizing unnecessary EVD manipulation during catheterization is crucial in order to decrease the risk of EVD infection.

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Efficacy of periprocedural vs extended use of antibiotics in patients with external ventricular drains – A randomized trial

Cited by 3 publications

References 19 publications

The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement

The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement

Concentrations of Cefuroxime in Brain Tissue of Neurointensive Care Patients

Risk Assessment and Recommended Approaches to Optimize Infection Control and Antibiotic Stewardship to Reduce External Ventricular Drain Infection: A Single-Center Study

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