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Bacteriële CZS infecties

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Initiatief: SWAB Aantal modules: 9
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Intraventriculaire antibiotica behandeling

Beoordeeld: 01-01-2012

Uitgangsvraag

Intraventricular antibiotic treatment.

Aanbeveling

Intraventricular antibiotic treatment can be used to treat infections that react poorly to parental antibiotics alone, but indications are not well defined. 

 

The dosage of intraventricular treatment needs to be adjusted to the CSF antibiotic concentration, and should be 10-20 times the minimal inhibitory concentration of the causative micro-organism.

Overwegingen

For this module no considerations have been formulated. 

Onderbouwing

*

No randomized controlled trials or comparative studies have been performed to evaluate the indications and regimens of intraventricular antimicrobial treatment.

What are the indications and regimens for intraventricular antimicrobial treatment?

Direct infusion of antimicrobial agents into the ventricles through external ventricular catheters is sometimes necessary to treat infections after neurosurgical procedures or infections associated with CSF catheters that are difficult to eradicate with parenteral antibiotics alone.4,28,61,62 The indications for intraventricular antibiotics are however, not well defined. The antibiotic is administered through the catheter, which should subsequently be closed for one hour. Dosages have been determined empirically and are generally adjusted according to the measured CSF concentration of the antibiotic.4 Determination of CSF antibiotic concentration is performed in a sample taken just before the next dose. The trough concentration should be at least 10-20 times the minimal inhibitory concentration to achieve a constant sterilization of CSF.4 Antibiotics most used for intraventricular administration are vancomycin and gentamicin (Table 1, adapted from 4).

 

Table 1. Recommended dosages of antimicrobial agents administered by the intraventricular route.a 

Antimicrobial agent

Daily intraventricular dose (mg)

Vancomycin

5-20b

Gentamicin

1-8c

Tobramycin

5-20

Amikacin

5-50d

Polymyxin B

5e

Colistin

10-20f

Quinupristin/dalfopristin

2-5

aThere are no data that define the exact dose of an antimicrobial agent that may be administered by the intraventricular route, but guidance may be given by use of MIC (see text) for use of agents in which concentrations can be measured. Medications administered by the intraventricular route should be preservativefree; bMost studies have utilized a 10 mg or 20 mg dose;  cUsual daily dose is 1-2 mg for infants and children, and 4-8 mg for adults; dThe usual daily dose is 30 mg;  eDosage in children is 2 mg daily; fIn one study, patients received 10 mg administered every 12 hours.

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  116. Mayhall CG, Archer NH, Lamb VA et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 1984; 310: 553-9.
  117. Stenager E, Gerner-Smidt P, Kock-Jensen C. Ventriculostomy-related infections--an epidemiological study. Acta Neurochir (Wien ) 1986; 83: 20-3.
  118. Ohrstrom JK, Skou JK, Ejlertsen T, Kosteljanetz M. Infected ventriculostomy: bacteriology and treatment. Acta Neurochir (Wien ) 1989; 100: 67-9.
  119. Coplin WM, Avellino AM, Kim DK, Winn HR, Grady MS. Bacterial meningitis associated with lumbar drains: a retrospective cohort study. J Neurol Neurosurg Psychiatry 1999; 67: 468-73.
  120. Lyke KE, Obasanjo OO, Williams MA, O'Brien M, Chotani R, Perl TM. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis 2001; 33: 2028-33.
  121. Wong GK, Poon WS, Wai S, Yu LM, Lyon D, Lam JM. Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2002; 73: 759-61.
  122. Pfisterer W, Muhlbauer M, Czech T, Reinprecht A. Early diagnosis of external ventricular drainage infection: results of a prospective study. J Neurol Neurosurg Psychiatry 2003; 74: 929-32.
  123. Park P, Garton HJ, Kocan MJ, Thompson BG. Risk of infection with prolonged ventricular catheterization. Neurosurgery 2004; 55: 594-9.
  124. Arabi Y, Memish ZA, Balkhy HH et al. Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control 2005; 33: 137-43.
  125. Leverstein-van Hall MA, Hopmans TE, van der Sprenkel JW et al. A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. J Neurosurg 2010; 112: 345-53.
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  127. Walters BC, Hoffman HJ, Hendrick EB, Humphreys RP. Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 1984; 60: 1014-21.
  128. Filka J, Huttova M, Tuharsky J, Sagat T, Kralinsky K, Krcmery V, Jr. Nosocomial meningitis in children after ventriculoperitoneal shunt insertion. Acta Paediatr 1999; 88: 576-8.
  129. Kestle JR, Garton HJ, Whitehead WE et al. Management of shunt infections: a multicenter pilot study. J Neurosurg 2006; 105: 177-81.
  130. Sacar S, Turgut H, Toprak S et al. A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period. BMC Infect Dis 2006; 6:43.: 43.
  131. Aucoin PJ, Kotilainen HR, Gantz NM, Davidson R, Kellogg P, Stone B. Intracranial pressure monitors. Epidemiologic study of risk factors and infections. Am J Med 1986; 80: 369-76.
  132. Kourbeti IS, Jacobs AV, Koslow M, Karabetsos D, Holzman RS. Risk factors associated with postcraniotomy meningitis. Neurosurgery 2007; 60: 317-25.
  133. Federico G, Tumbarello M, Spanu T et al. Risk factors and prognostic indicators of bacterial meningitis in a cohort of 3580 postneurosurgical patients. Scand J Infect Dis 2001; 33: 533-7.
  134. Wang KW, Chang WN, Huang CR et al. Post-neurosurgical nosocomial bacterial meningitis in adults: microbiology, clinical features, and outcomes. J Clin Neurosci 2005; 12: 647-50.
  135. Zarrouk V, Vassor I, Bert F et al. Evaluation of the management of postoperative aseptic meningitis. Clin Infect Dis 2007; 44: 1555-9.

Autorisatiedatum en geldigheid

Laatst beoordeeld  : 01-01-2012

Laatst geautoriseerd  : 01-01-2012

Geplande herbeoordeling  :

Initiatief en autorisatie

Initiatief:
  • Stichting Werkgroep Antibioticabeleid
Geautoriseerd door:
  • Nederlandse Vereniging voor Kindergeneeskunde
  • Nederlandse Vereniging voor Medische Microbiologie
  • Nederlandse Vereniging voor Neurochirurgie
  • Nederlandse Vereniging voor Neurologie

Algemene gegevens

The Dutch Working Party on Antibiotic Policy (SWAB; Stichting Werkgroep Antibiotica Beleid), established by the Dutch Society for Infectious Diseases (VIZ), the Dutch Society of Medical Microbiology (NVMM) and the Dutch Society for Hospital Pharmacists (NVZA), develops evidence-based guidelines for the use of antibiotics in hospitalized patients in order to optimize the quality of prescribing, thus, contributing to the containment of antimicrobial drug costs and resistance. By means of the development of national guidelines, SWAB offers local antibiotic and formulary committees a guideline for the development of their own, local antibiotic policy.  These are the first SWAB guidelines on bacterial central nervous system infections. It is developed according to the Evidence Based Guideline Development method (EBRO; www.cbo.nl). The AGREE criteria

(www.agreecollaboration.org) provided a structured framework both for the development and the assessment of the draft guideline. 

 

Relationship between the SWAB Guidelines and the 2012 Guidelines on Meningitis by the Dutch Society for Neurology (Nederlandse Vereniging voor Neurologie)

The SWAB guidelines cover the antimicrobial therapy in children and adults with bacterial meningitis, brain abscesses and tuberculous meningitis. They do not cover other treatment components of bacterial meningitis, such as corticosteroids, osmotic agents and anticoagulants.2 This is discussed extensively in the 2012 guidelines by the Dutch Society for Neurology (Nederlandse Vereniging voor Neurologie). The Nederlandse Vereniging voor Neurologie guidelines adopted the SWAB guidelines on meningitis to be the treatment part of their meningitis guidelines.

Doel en doelgroep

Core issues on cryptococcal meningitis are extensively discussed in the 2008 SWAB guidelines on fungal infections. Diagnostics for bacterial meningitis are briefly discussed in the introduction, but not systematically reviewed in these guidelines. Encephalitis falls outside the scope of these guidelines.

For this guideline we made a distinction based on the setting in which bacterial meningitis was acquired: community-acquired versus nosocomial. Further, we provide recommendations for empirical antimicrobial therapy for clinical subgroups of bacterial meningitis patients. The choice of initial antimicrobial therapy for these subgroups is based on the bacteria most commonly causing the disease, taking into account the patient’s age and clinical setting, and patterns of antimicrobial susceptibility. After the results of culture and susceptibility testing have become available, antimicrobial therapy can be modified for optimal treatment. 

Samenstelling werkgroep

Preparatory Committee: Dr. M.C. Brouwer, Drs. S.G.B. Heckenberg, Dr. G.T.J. van Well (Nederlandse Vereniging voor Kindergeneeskunde), Dr. A. Brouwer (Vereniging voor Infectieziekten), Dr. E.J. Delwel (Nederlandse Vereniging voor Neurochirurgie), Dr. L. Spanjaard (Nederlandse Vereniging voor Medisch Microbiologie), Prof. dr. D. van de Beek (Nederlandse Vereniging voor Neurologie), Prof. dr. J.M. Prins (SWAB).

Methode ontwikkeling

Evidence based

Werkwijze

Twelve key questions were formulated concerning the antibiotic treatment of bacterial central nervous system infections. Using several data sources (see data sources) conclusions were drawn, with their specific level of evidence, according to the CBO grading system adopted by SWAB (Table 1).1

Subsequently, specific recommendations were formulated. Each key question will be answered in a separate chapter. 

 

Table 1a

Methodological quality of individual studies.1

 

 

Intervention

Etiology, prognosis

A1 

Systematic review of at least two independent A2-level studies 

A2 

Randomised Controlled Trial (RCT) of sufficient methodological quality and power 

Prospective cohort study with sufficient power and with adequate confounding corrections 

B 

Comparative Study lacking the same quality

as mentioned at A2 (including patientcontrol and cohort studies) 

Prospective cohort study lacking the same quality as mentioned at A2, retrospective cohort study or patient-control study 

C 

Non-comparative study 

D 

Expert opinion 

 

Table 1b

Level of evidence of conclusions

 

 

Conclusions based on 

1 

Study of level A1 or at least two independent studies of level A2 

2 

One study of level A2 or at least two independent studies of level B 

3 

One study of level B or C 

4 

Expert opinion 

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Bacterieel intracerebraal absces