Factors and measures predicting external CSF drain-associated ventriculitis

Abstract

ObjectiveTo determine the diagnostic value of clinical factors and biochemical or microbiological measures for diagnosing a drain-associated ventriculitis, we summarized the available evidence.MethodsWe 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.ResultsWe 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%).ConclusionClinical 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.

Bacterial external ventricular catheter-associated infection

“…The latter is the most common cause of EVD-associated infection [8]. Causative bacterial pathogens are skin commensals such as Gram-positive coagulase-negative staphylococci, Staphylococcus aureus, and Gram-negatives Escherichia coli, Acinetobacter spp., and Klebsiella spp [4]. Many bacterial pathogens are able to produce a biofilm on the drain hampering effective antimicrobial therapy [9,10].…”

“…Symptoms of infection may be masked by the primary neurological condition and a neurosurgical intervention itself may cause a sterile inflammatory response further hampering the diagnostic process of ventricular catheter-associated infections [2]. These diagnostic dilemmas may result in delayed treatment of patients with bacterial infection as well as unnecessary antimicrobial therapy [3,4]. In this narrative review, we describe the diagnostic accuracy of clinical factors and biochemical and microbiological measures, discuss preventive measurements, and provide insight into the treatment approach of patients with external ventricular catheter-associated infection.…”

Metagenomic Next-Generation Sequencing of Cerebrospinal Fluid for the Diagnosis of External Ventricular and Lumbar Drainage-Associated Ventriculitis and Meningitis

“…VM is an acute complication associated with neurosurgery and may lead to permanent adverse outcomes if not managed properly (Beer et al, 2008). The incidence of VM rates was reported to range from 2 to 45% (Dorresteijn et al, 2019), and the predisposing factors for VM include non-adherence to rigid insertion and maintenance protocols, leakage of CSF, catheter irrigation, and the frequency of EVD or LD manipulation. Meanwhile, our study indicated the same results in cVM and sVM (39 and 49 of 102 patients, respectively).…”

“…External ventricular drains (EVDs) and, in some specific cases, lumbar drains (LDs) are essential to drain cerebrospinal fluid (CSF) and control intracranial pressure after neurosurgery (Brain Trauma Foundation et al, 2007;Carney et al, 2017). One of the risks surrounding the placement and maintenance of catheters is the infection of cerebrospinal fluid (CSF), with infection rates ranging from 2 to 45% (Lozier et al, 2008;Scheithauer et al, 2010;van de Beek et al, 2010;Dorresteijn et al, 2019). EVD/LDassociated ventriculitis and meningitis (VM) are correlated with high rates of morbidity and mortality, significantly prolonged lengths of hospitalization (LOS), elevated hospital costs, and negatively affected prognosis (Citerio et al, 2015;Hussein et al, 2019).…”

Pre-operative External Ventricle Drainage Improves Neurological Outcomes for Patients with Traumatic Intracerebellar Hematomas

“…Once hydrocephalus has occurred, it is probable to miss the best opportunity to rescue the patients by placing EVD. However, if the EVD is placed in advance, it may increase the risk of infection and supratentorial hemorrhage [9][10][11][12]. Therefore, there is still debate about when to place the EVD on TICH.…”