2.4 CSF shunt infections
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| CNS device infections in stable patients | Vancomycin 25 mg/kg IV stat followed by 15mg/kg q 8-12h + Ceftazidime 2g IV q8h Or Cefepime 2g IV q8h | For confirmed shunt infections, the shunt should be removed and a temporary external ventricular drain inserted. The shunt should be sent for cultures. Adjunctive intraventricular antibiotics are not routinely necessary for treatment of CSF shunt infections. Intraventricular antibiotics may be required for: infections that are refractory to appropriate systemic antibiotic therapy, infections caused by highly resistant organisms susceptible only to antimicrobials with poor CSF penetration, and infections in which the shunt cannot be removed. When intraventricular antibiotics are used, they should be administered in combination with intravenous therapy. Uncomplicated shunt infections can be treated with a total course of 7–12 days of intra-ventricular and intravenous antibiotics. Complicated shunt infections can be treated with 2 weeks intra- ventricular (given OD) and 3 weeks intravenous antibiotics. Complicated shunt infections are defined for the purpose of this protocol as multiple compartment hydrocephalus, multiple organism shunt infection, severe peritonitis, or infections in other sites of the body. | |
| In sick patients | Vancomycin 25 mg/kg IV stat followed by 15mg/kg q8-12h + Meropenem 2g IV 8 h |
For common etiological agents of CSF shunt infections, see Annexure B.2.4
Additional Information
- The time of shunt re-implantation depends on the causative organism and extent of infection. It can be done as soon as after 2 days of negative cultures in patients with CoNS and normal CSF sugar, or 7 days of negative cultures in patients with CoNS and abnormal CSF findings, 10 days of negative cultures in patients with infection with S. aureus/ gram negative bacilli. The total duration of antimicrobial therapy varies from 7-10 days for CoNS to 10-14 days for S. aureus and Gram-negative bacilli.
- The Infectious Diseases Society of America guidelines recommended intrathecal/intraventricular therapy daily dose of colistin 10 mg of CMS or colistimethate sodium (about 125 000 IU CMS; 3.75 mg CBA).
- Doses of other intra-ventricular antibiotics:
- Colistin: 125,000 IU for 9 to 16 days
- Vancomycin: 12.2 mg/day for 5 days
- Gentamicin/tobramycin: 6.7 mg/day for 6 days
- Doses of drugs to be given by the intrathecal/ intraventricular route (CSF shunt infections) are tabulated below:
|
Drug |
Dose |
|
Vancomycin |
5-20 mg |
|
Teicoplanin |
5-40 mg |
|
Amikacin |
5-50 mg |
|
Gentamicin |
1-8 mg |
|
Colistin |
10-20 mg |
|
PolymyxinB |
50,000 units |
|
Daptomycin |
2-5 mg |
|
Tobramycin |
5-20 mg |
References
1. Robinson JL, Freire D, Bialy L. Treatment strategies for cerebrospinal shunt infections: a systematic review of observational studies. BMJ Open. 2020 Dec 10;10(12): e038978. doi: 10.1136/bmjopen-2020-038978. PMID: 33303443; PMCID: PMC7733168.
2. James HE, Bradley JS. Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr. 2008 Mar;1(3):223-8. doi: 10.3171/PED/2008/1/3/223. PMID: 18352767.
3. Eljaaly K. Dose and duration of intraventricular antibiotic therapy in meningitis. Clin Microbiol Infect. 2016 Sep;22(9):817. doi: 10.1016/j.cmi.2016.05.019. Epub 2016 May 30. PMID: 27256064.
4. Lewin JJ 3rd, Cook AM, Gonzales C, Merola D, Neyens R, Peppard WJ, Brophy GM, Kurczewski L, Giarratano M, Makii J, Rowe AS, Tesoro EP, Zaniewski A, Clark S, Ziai WC. Current Practices of Intraventricular Antibiotic Therapy in the Treatment of Meningitis and Ventriculitis: Results from a Multicenter Retrospective Cohort Study. Neurocrit Care. 2019 Jun; 30(3):609-616. doi: 10.1007/s12028-018-0647-0. PMID: 30446934.