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Nosocomiale bacteriële meningitis

Beoordeeld: 01-01-2012

Uitgangsvraag

Epidemiology and empirical antibiotic treatment of nosocomial and posttraumatic bacterial meningitis.

Aanbeveling

Nosocomial meningitis associated with external or internal ventricular drains should be empirically treated with vancomycin plus either ceftazidime or meropenem.

 

Postoperative bacterial meningitis should be treated with flucloxacillin combined with ceftazidime, or with meropenem monotherapy.

 

Posttraumatic bacterial meningitis due to a skull base fracture should be treated with a third generation cephalosporin.

 

Posttraumatic bacterial meningitis due to open skull fractures should be empirically treated with a third generation cephalosporin (ceftriaxone or cefotaxime).

Overwegingen

For this module no considerations have been formulated. 

Onderbouwing

Level 2

Bacterial meningitis related to external and internal ventricular drains, and postoperative  bacterial meningitis is caused by Staphylococcus spp. in 50-60% of cases

 

B Vinchon (2006)45, Conen (2008)46, Walters (1984)47, Filka (1999)48, Kestle (2006)49, Sacar (2006)50, McClelland (2007)52, Aucoin (1986)53, Kourbeti (2007)54, Federico

(2001)55, Wang (2005)56, Zarrouk (2007)57

 

Level 4

Bacterial meningitis following severe head trauma due to skull base fractures is mostly caused by S. pneumoniae, H. influenzae and group A streptococci and bacterial meningitis due to open skull fractures is mostly caused by skin flora (staphylococci).

 

 

*

No studies have been performed on empirical antibiotic therapy for nosocomial bacterial meningitis

What is the epidemiology and empirical treatment of bacterial meningitis related to external CSF drainage?

External ventricular and lumbar drains are used for monitoring  intracranial pressure and temporary diversion of CSF, or as part of treatment of infected internal catheters.4 The risk of infection of external ventricular catheters is reported to be approximately 8%, while infection of external lumbar catheters has been estimated to occur in 5%.34 Most common pathogens in infections of external CSF catheters are staphylococci, which are cultured in approximately 60% of cases. Common staphylococcal species are coagulase-negative staphylococci, mostly S. epidermidis, and S. aureus ( table 2).35-44 Other common pathogens are Klebsiella pneumoniae, Enterobacter species, Enterococcus faecalis, Acinetobacter species and Pseudomonas aeruginosa. Multiple uncommon pathogens can be found in external CSF catheter infection and therefore empirical antibiotic coverage should be broad. A combination of vancomycin plus either ceftazidime or meropenemshould be used (Table 1).4

 

What is the epidemiology and empirical treatment of bacterial meningitis related to internal CSF drainage?

The reported incidence of meningitis associated with internal ventricular or lumbar catheters ranges from 4 to 17%.4,45,46  Approximately 60% of cases are caused by Staphylococcus species, and other frequent pathogens are Escherichia coli, K. pneumoniae, E. faecalis and Acinetobacter species (table 3).45-50 Mixed infections were described in 17% of cases in a recent Swiss study including 71 patients.46 Because of the wide range of pathogens and the occurrence of mixed infections the antibiotic coverage should be broad and should consist of vancomycin plus either ceftazidime or meropenem(Table 1).4

 

What is the epidemiology and empirical treatment of bacterial meningitis related to postoperative bacterial meningitis?

Bacterial meningitis is a serious complication of neurosurgical procedures and occurs in 0.8-1.5% of patients who undergo craniotomy.4,51,52 Development of bacterial meningitis has been associated with concomitant infection of the site of incision and duration of operation > 4 hours.4 One third of meningitis cases develop within the first week after the operation, one third in the second week and one third after the second week.51 Most cases are caused by Staphylococcus species (coagulase negative staphylococci, mostly S. epidermidis and S. aureus; Supplementary table 452-57). E. coli, K. pneumoniae, Enterobacter spp, Serratia spp, Acinetobacter spp, and P. aeruginosa were all found in approximately 5% of cases. Frequent causes of community-acquired bacterial meningitis such as Streptococcus pneumoniae and Haemophilus influenzae occur infrequently in postoperative bacterial meningitis. Because the significance of coagulase negative staphylococci is not evident in the patients without internal or external drains, and vancomycin is inferior to β-lactam antibiotics in S.aureus infections, empirical therapy should consist of flucloxacillin combined with ceftazidime, or meropenem monotherapy.

 

What is the epidemiology and empirical treatment of posttraumatic bacterial meningitis?

 The incidence of meningitis after moderate and severe head trauma is estimated at 1.4%.4,58 In patients with open cranial fractures the rate of meningitis is higher at 2-11%. Data on causative microorganisms in posttraumatic bacterial meningitis are scarce (table 5).58 Posttraumatic meningitis following skull base fractures are caused by microorganisms that colonize the nasopharynx (S. pneumoniae, H. influenzae and Group A streptococci),4while bacterial meningitis following an impression fracture of the skull will be likely caused by skin flora (staphylococci). Also in these patients the significance of coagulase negative staphylococci is not evident in the absence of internal or external drains, and vancomycin is inferior to β-lactam antibiotics in S.aureus infections. Therefore, empirical therapy in patients with skull base fractures consists of a third generation cephalosporin, and  patients with bacterial meningitis following open skull fractures should likewise be treated with a third generation cephalosporin (ceftriaxone or cefotaxime)(Table 1).

 

Table 1. Empirical treatment of nosocomial bacterial meningitis in different subgroupsa

Pathogenesis

Common bacterial pathogens

Antimicrobial therapya

Postneurosurgery

Ventricular or lumbar catheter

Aerobic gram-negative bacilli, S. aureus, CNSb  

CNSb, S. aureus, aerobic gramnegative bacilli, Propionibacterium acnes

 

Flucloxacillin plus either ceftazidime, or meropenem monotherapyc,d

Vancomycin plus either ceftazidime or meropenemc,d

 

 

Penetrating trauma

S. aureus, CNSb, aerobic gramnegative bacilli

Third-generation cephalosporind,e

Basilar skull fracture

(early)

S. pneumoniae, H. influenzae, group

A ß–hemolytic streptococci

Third-generation cephalosporind,e

 

aThe preferred daily dosages of antimicrobial agents in adult patients with normal renal and hepatic function are as follows: vancomycin 1000 mg every 12 hours, to be adjusted to maintain a serum vancomycin trough concentration of 15-20 µg/ml, ceftazidime 2 grams every 8 hours, meropenem 2 grams every 8 hours; in patients with severe penicillin and/or cephalosporin allergy, ciprofloxacin 400 mg every 8 hours can be used for treatment of infection caused by gram-negative bacilli; ceftriaxone 2 grams every 12 hours, cefotaxime 2 grams every 4 hours;

bCoagulase-negative Staphylococcus (mostly S. epidermidis) cChoice of specific agent should be based on local antimicrobial susceptibility of aerobic gram-negative bacilli; dFor patients with severe allergy to penicillin and/or cephalosporins, a fluoroquinolone with in vitro activity against P. aeruginosa should be utilized;  eCeftriaxone or cefotaxime.

 

Table 2 Bacterial meningitis in patients with external CSF drains

Study

Mayhall116 Stenager117 Ohrstrom118

Coplin119    Lyke120      Wong121      Pfisterer122 Park123        Arabi124           Leverstein125 Schade126 Total (%)

Study period 

Country

1979-1981

US

1984

Denmark

1981-1986

Denmark

1992-1995

US

1995-1998

US

1998-2000

China

1993-1995

Austria

1995-2003

US

1999-2002

SaudiArabia

2004-2006

NL 

1999-2003

NL

 

 

Gram-positive bacteria 

 

 

 

 

 

 

 

 

 

 

 

 

Streptococcus pyogenes

1

 

 

  1

 

 

 

 

 

 

 

2 (0.7%)

Streptococcus mitis 

1

 

 

 

 

 

 

 

 

 

 

1 (0.4%)

Streptococcus morbillorum

 

 

 

 

 

 

1

 

 

 

 

1 (0.4%)

Streptococcus sppa

 

1

 

 

 

 

1

 

1

 

 

3 (1.1%)

Enterococcus faecalis

1

1

 

 

 

 

2

 

2

5

2

13 (4.8%)

Staphylococcus aureus

1

 

9

2

 

 

5

 

1

10

6

34 (12.6%)

Staphylococcus epidermidis

 

12

 

 

 

 

16

 

 

 

 

28 (9.4%)

CNSb  

6

 

15

6

2

2

1

31

3

20

9

95 (35.3%)

Staphylococcus saprophyticus

 

 

 

 

 

 

1

 

 

 

 

1 (0.4%)

Corynebacterium spp.

 

 

 

1

 

 

2

2

 

 

 

5 (1.9%)

Bacillus spp.

 

 

 

 

 

 

 

1

 

2

1

4 (1.5%)

Gram-negative bacteria

 

 

 

 

 

 

 

 

 

 

 

 

 

Escherichia coli

1

 

 

 

 

 

 

 

 

3

1

5 (1.9%)

Klebsiella pneumoniae

1

 

2

1

4

 

2

1

 

2

1

14 (5.2%)

Enterobacter spp.

2

 

 

1

2

 

4

1

4

2

 

16 (5.9%)

Serratia spp.

1

 

 

 

1

 

 

1

 

 

 

3 (1.1%)

Proteus spp.

 

 

 

 

1

 

 

1

 

 

1

3 (1.1%)

Acinetobacter spp.

2

1

1

1

 

2

1

1

6

 

1

16 (5.9%)

Pseudomonas

aeruginosa

 

 

 

1

 

 

2

2

2

1

 

8 (3.0%)

Flavobacterium spp.

 

 

 

 

 

 

 

1

 

 

 

1 (0.4%)

Mixed

 

 

 

1

 

 

 

4

 

1

 

6 (2.2%)

Other

1

 

 

 

1

 

6

2

 

 

 

10 (3.7%)

Total 

19

16

27

13

11

6

44

51

19

46

22

269

 aNot specified,bCoagulase-negative Staphylococcus

 

Table 3 Bacterial meningitis in patients with internal CSF drains

Study

Walters127

 Filka128       

Vinchon45

Kestle129

Sacar130

Conen46

Study period 

1960-1979

1990-1997

1985-2005

2001-2004

2000-2004

1996-2006  

Country

Canada

Slovakia

France

US

Turkey

Switzerland 

Gram-positive bacteria

Streptococcus pneumoniae

 

 

 

 

 

2

 

 

 

 

 

 

 

2 (0.3%)

Streptococcus agalactiae

 

1

 

 

 

 

1 (0.2%)

Streptococcusa

 

1

 

 

 

3

4 (0.6%)

Enterococcus faecalis 

24

4

11

 

1

1

41 (6.3%)

Staphylococcus aureus

77

7

23

9

6

14

136 (20.9%)

CNSb

 

28

 

 

 

29

57 (8.8%)

Staphylococcus epidermidis

128

 

36

34

3

 

201 (30.9%)

Listeria monocytogenes

 

 

1

 

 

 

1 (0.2%)

Gram-negative bacteria

Neisseria meningitidis 

 

 

 

 

 

1

 

 

 

 

 

 

 

1 (0.2%)

Haemophilus influenzae

 

 

7

 

 

 

7 (1.1%)

Flavobacterium spp.

 

 

 

 

1

 

1 (0.2%)

Escherichia coli

48

 

 

 

1

 

49 (7.5%)

Klebsiella pneumoniae

43

 

 

 

1

 

44 (6.8%)

Enterobacter spp.

 

1

 

 

1

3

5 (0.8%)

Acinetobacter spp.

 

6

 

 

4

 

10 (1.5%)

Pseudomonas aeruginosa

19

4

 

 

2

 

25 (3.8%)

Gram negative rodsa

 

 

19

 

 

 

19 (2.9%)

Mixed

 

 

 

 

 

12

12 (1.8%)

Other

8

 

 

27

 

 

35 (5.4%)

Total number of episodes

222

33

102

70

20

71

518 

Total cultured bacteria

347

53

102

70

20

83

651

 aNot specified,bCoagulase-negative Staphylococcus

 

Table 4 Postoperative bacterial meningitis

Study 

McLelland III52

Aucoin131

Kourbeti132

Federico133

Wang134

Zarrouk135

 

Study period 

1991-2005

1976-1981

1996-2000

1989-1997

1986-2001

1998-2005

 

Country

USA

USA

USA

Italy

Taiwan

France

 

Gram-positive bacteria

Streptococcus pneumoniae

 

 

 

 

 

 

 

 

 

3

 

2

 

5 (3.0%)

Streptococcus spp.a

 

 

 

 

3

2

5 (3.0%)

Enterococcus faecalis

 

 

1

 

1

 

2 (1.2%)

Staphylococcus aureus

8

2

2

9

13

5

39 (23.2%)

CNSb

 

1

5

 

7

3

16 (9.5%)

Staphylococcus epidermidis

 

 

 

19

 

 

19 (11.3%)

Corynebacterium

 

 

 

2

 

 

2 (1.2%)

Propionibacterium acnes

4

 

 

 

 

 

4 (2.4%)

Bacillus spp.

 

 

1

 

1

 

2 (1.2%)

Gram-negative bacteria

Haemophilus influenzae

 

 

 

 

 

1

 

 

 

1

 

2

 

4 (2.4%)

Escherichia coli

 

1

 

 

5

2

8 (4.8%)

Klebsiella pneumoniae

 

4

 

 

3

1

8 (4.8%)

Klebsiella oxytoca

 

 

 

 

1

 

1 (0.6%)

Enterobacter spp.

 

1

 

1

3

1

6 (3.6%)

Serratia spp.

 

1

2

3

1

1

8 (4.8%)

Proteus spp.

 

 

 

 

1

 

1 (0.6%)

Morganella morganii

 

 

 

 

1

1

2 (1.2%)

Acinetobacter spp.

 

 

1

4

4

 

9 (5.4%)

Pseudomonas aeruginosa 

1

 

1

1

5

 

8 (4.8%)

Mixed

2

2

3

7

5

 

19 (11.3%)

 aNot specified, bCoagulase-negative Staphylococcus

 

Table 5 Posttraumatic bacterial meningitis

Study

Baltas58

Country

Greece

Study period

1987-1992

Gram-positive

Staphylococcus haemolyticus

 

1

Staphylococcus cohnii 

1

Staphylococcus epidermidis 

1

Streptococcus  pneumoniae 

1

Gram-negative

Escherichia coli

 

2

Klebsiella pneumoniae

2

Acinetobacter anitratus

2

Total

11 

 
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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
  • Stichting Werkgroep Antibioticabeleid

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 

Zoekverantwoording

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Behandeling van postoperative meningitis