Ventriculostomy-Associated Infection: A New, Standardized Reporting Definition and Institutional Experience

Abstract

Our standardized VAI definition and CDC format seems promising toward facilitating future study and guideline development. Given our strict protocol of sterile catheter placement and care, and our institution's low 2.0% infection rates, we propose an infection-rate target of ≤5 per 1,000 device days. Our results suggest that the use of antibiotics or antibiotic-impregnated catheters is unwarranted--a positive given concerns of evolving anti-microbial resistance.

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

“…The defined time at which a positive CSF culture first qualified as a VRI varied from any time after catheter insertion 9 to 24 11,16 to 48 4 hours after placement. The timeframe at which VRI is diagnosed after EVD removal also varied from three days 12 to four weeks 25 after EVD removal.…”

“…While some used vague terms such as “clinical picture” 13 or “clinical signs” 18,23 of infection, others used a quantitative scale 18,19 , or specified individual clinical signs and symptoms including cranial nerve signs, headache 25 , photophobia, seizures 15,21 , stiff neck 21,25 , altered mental status 9,15,21 , irritability 9,25 , inflammation at the catheter site 9 , and fever. In some cases fever was undefined 15,18,19,21 , and in others it was defined as 38 25 , 38.5 10 , and 38.6 degrees Celsius 12 .…”

“…The CDC definition is not widely employed to evaluate frequency of VRI 4,9–23 , largely because it does not include exclusion criteria to eliminate contaminants 23 and does not contain specific timing criteria to determine when a case of ventriculitis should be attributed to a ventriculostomy. As a result, one of the hypothesized reasons for the degree of variation in frequency of VRI is the lack of consensus on the definition for VRI 9–12,14,15,19 . In order to determine the effect that varying definitions of VRI have on frequency of diagnosis, we sought to review published definitions for VRI and apply them to a test cohort of positive CSF cultures taken from EVDs at two institutions then evaluate the strength of each definition by determining how accurately it identified clinically treated cases in the test cohort.…”

Complications of invasive intracranial pressure monitoring devices in neurocritical care

“…38 To further illustrate the variability in defining VAIs, one study applied criteria from Honda et al, Gozal et al, and Citerio et al to a retrospective series and found that rates of infection based on each authors' criteria were 60%, 56%, and 23%, respectively. 11,25,30,51 In 2014, Gozal et al proposed a standardized definition of VAIs as a positive CSF culture in a patient with a ventriculostomy catheter and one of the following: a fever > 101.5°F, a CSF glucose level < 50 mg/dl, or a CSF glucose level < 50% of any serum glucose drawn within 24 hours of CSF sample. 25 Most recently, the 2017 Infectious Diseases Society of America guidelines on healthcare-associated ventriculitis and meningitis did not give a definition of VAI, but provided guidance for when clinical suspicion prompts CSF sampling for infection.…”

“…11,25,30,51 In 2014, Gozal et al proposed a standardized definition of VAIs as a positive CSF culture in a patient with a ventriculostomy catheter and one of the following: a fever > 101.5°F, a CSF glucose level < 50 mg/dl, or a CSF glucose level < 50% of any serum glucose drawn within 24 hours of CSF sample. 25 Most recently, the 2017 Infectious Diseases Society of America guidelines on healthcare-associated ventriculitis and meningitis did not give a definition of VAI, but provided guidance for when clinical suspicion prompts CSF sampling for infection. CSF pleocytosis with a positive culture and infectious symptoms are indicative of VAI, a strong recommendation with a high level of evidence.…”