Healthcare-associated ventriculitis: current and emerging diagnostic and treatment strategies

ABSTRACT

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.

KEYWORDS:

• Healthcare-associated ventriculitis and meningitis
• central nervous system devices
• cerebrospinal fluid shunts
• external ventricular devices
• diagnosis
• management

Article highlights

• Healthcare-associated ventriculitis and meningitis (HCAVM) more commonly occur associated with a central nervous system (CNS) device, after neurosurgical or otorhinological procedures, or post-head trauma.

• A CSF leak is a major risk factor for developing HCAVM, especially in association with an external ventricular device.

• The diagnosis of HCAVM is challenging as the sensitivity of CSF culture is suboptimal, is impacted by antibiotic therapy, and the CSF profile is unreliable.

• The management of suspected HCAVM should include cranial imaging, obtaining CSF studies before starting empiric antimicrobial therapy.

• Empirical antibiotic therapy should cover Staphylococcus aureus (e.g., vancomycin) and Pseudomonas aeruginosa (e.g., cefepime or meropenem) based on the local hospital antibiogram susceptibility patterns and all infected CNS devices should be removed.

• Intraventricular or intrathecal antimicrobial therapy should be considered as adjunctive therapy in patients that are not responding clinically or microbiologically to intravenous antibiotic therapy.

Declaration of interest

R Hasbun has received research support and personal fees from Biofire®. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This author has been funded by the Grant A Starr Foundation.