2.5 Healthcare Associated Ventriculitis
| Type of Infection | First Line (with Dosage and Duration) |
Alternative First Line (with dosage and Duration) |
Comments |
|---|---|---|---|
| Complicated (Meningitis-Post- neurosurgery or Penetrating head trauma or with basilar skull fractures) | Meropenem 2g IV q8h + Vancomycin 25 mg/kg IV stat followed by 15mg/kg q 8-12h + If local antibiograms of healthcare associated ventriculitis are suggestive of high incidence of carbapenem resistant Gram- negative bacteria; then add cover for carbapenem resistant organisms (Inj Fosfomycin 4g IV q6h or Inj Polymyxin B 15lacs IV stat and 7.5lacs IU BD) Duration of treatment: 14 -21 days | Healthcare associated Ventriculitis and meningitis maybe a sequelae of infections occurring in the proximal part of CSF shunts. |
For common etiological agents of Healthcare Associated Ventriculitis, see Annexure B.2.5
Additional Information
- May need intra ventricular antimicrobial therapy in severe cases.
- Factors which increase the risk of post neuro-surgical infections:
- CSF leak, CSF drainage, prolonged duration of surgery (> 4 hours), venous sinus surgery, implantation of foreign materials, posterior approach to spinal surgery, diabetes, tobacco smoking, previous neuro-surgeries, hair shaving in ventriculo-peritoneal shunt placement.
- Guidance on the microbiological specimens to be submitted to the laboratory when shunt infections are suspected is tabulated below:
|
S.No. |
SuspectedConditionandtimeof collection |
Specimentobecollected |
| 1. |
Community Acquired Meningitis Suspected in a Shunted Patient |
CSF by LP not through the shunta |
| 2. |
Suspected Shunt Infection – Ventriculitis at Time of Presentation |
CSFa from: -
If there is an obstacle to obtain the appropriate specimen and a less useful specimen is collected then the specimen needs to be clearly labeled stating the collection method with liaison with the laboratory |
| 3. |
At Procedure of Surgical Removalb |
Ventricular catheter Various sites of Shunt tubing “proximal, distal” The Spitz-Holter valve Reservoir “if present” Intraventricular portion of EVD if applicable |
| 4. |
Following Shunt Removalc |
CSF from the temporary EVD apparatus every other day to check for sterility and schedule for a new shunting |
| 5. |
During re-shunting surgery |
CSF and external wound Avoid unnecessary sampling and introduction of organisms in the new apparatus |
| 6. |
After surgery |
As clinically indicated. Minimize invasive procedures to avoid iatrogenic infection. |
-
a) In suspected cases of ventriculitis and meningitis collected CSF samples should be processed for Gram stain, analysis and culture (prefer to inoculate in automated blood culture bottle at bed side for better yield);
-
b) Microscopy from site of pathology and culture of various sites for bacteria, fungi and mycobacteria; samples should not be fixed in formalin;
-
c) CSF labeled as D1, D3, D5 etc: Gram stain, Analysis, (Giemsa for sterility) & Culture to be done. These clinical presentations should be managed at Tertiary Health Care Centres.
Doses of drugs used in CNS infections is tabulated below:
|
Drug |
Adultdose |
Paediatricdose |
|
Artesunate |
2.4 mg/kg 0,12 and 24 hours and then q 24 hrly |
< 20 kg 3 mg/kg at 0,12 and 24 hours and then q 24 hrly |
|
Acyclovir |
10 mg/kg 8 hrly |
10 mg/kg 8 hrly and in children below 12; 20 mg/kg 8 hrly |
|
Ceftriaxone |
2 g 12 hrly |
50 mg/kg 12 hrly |
|
Ceftazidime |
2 g q 6-8 hrly |
50 mg/kg 8 hrly |
|
Cefepime |
2 g 8-12 hrly |
50 mg/ kg 12 hrly |
|
Cefotaxime |
2 g 6 hrly |
50 mg/kg 6 hrly |
|
Meropenem |
2 g 8 hrly |
40 mg/kg 8 hrly |
|
Colistin |
9 million unit loading and then 3 million 8 hrly |
150,000 units/ kg loading and then 50,000 units/ kg 8 hrly |
|
Polymyxin B |
15,00,000 units loading and then 7,50,000 12th hrly Loading dose of 25,000 units/kg followed by a total daily dose of 25,000 units/kg divided into two doses of 12,500 units/kg every 12 hours. |
15-25,000 units/ kg loading and then 5000-7500 units/ kg 8 hrly |
|
Fosfomycin |
4 g 6 hrly |
75-100 mg/kg/dose 6 hrly |
|
Cotrimoxazole |
3-6 mg/kg of TMP TDS |
|
|
Vancomycin |
15 mg/kg (max 2 g) 8 hrly |
15 mg/kg 6 hrly |
|
Cloxacillin
|
2 g 4 hrly |
50 mg/kg 6 hrly |
|
Doxycycline |
100 mg 12 hrly |
1.5-2 mg/kg 12 hrly |
|
Chloramphenicol |
1-2 g 6 hrly |
25 mg/kg 6 hrly |
|
Rifampicin |
600 mg OD |
10-20 mg/kg OD |
|
Metronidazole
|
400 mg 8 hrly: Oral 500 mg 8 hrly: IV |
10 mg/kg 8 hrly |
|
Amphotericin B |
1 mg/kg/day |
|
|
Liposomal amphotericin B |
3-5 mg/kg/day |
|
|
Fluconazole |
800 mg loading and then 400 mg OD |
12 mg/kg loading and then 6 mg/ kg daily 25 mg/kg loading in neonates and then 12 mg/kg daily |