Morbidity and revision surgery secondary to ventriculostomy related infection remains high, even while using antibiotic impregnated catheters.
Failing to respond to systemic treatment or infection with a resistant organism might require intrathecal/intraventricular antibiotic administration. Many recommendations, however, are based on expert opinion because rigorous clinical data are not available. 1).
Systematic Review and Meta-Analysis
Combined Intraventricular antibiotic plus intravenous treatment did not prove superior to standard IV-only treatment in the management of VM. Nevertheless, weak evidence showed that IVT treatment might serve as an adjunct in the management of CRE pathogens 2).
Choose the antimicrobial based on susceptibility.
Dosages for intraventricular antibiotics:
○ Intraventricular Vancomycin: 5mg for slit ventricles, 10mg with normal-sized ventricles, 15–20mg for patients with enlarged ventricles.
○ Aminoglycoside: Dosing can also be tailored to ventricular size. Frequency can be adjusted based on drain output as well: once daily for drain output > 100 ml/day, every other day if drain output = 50–100 ml/day, every third day if drainage < 50 ml/day
– Gentamicin: 4–8mg
– Tobramycin: 5–20mg
– Amikacin: 5–30mg
○ Colistimethate sodium: 10mg CMS, which is 125,000 IU or 3.75mg CBA (Colistin Base units)
○ Daptomycin: 2–5mg
● After IT administration of an antimicrobial, clamp the drain for 15–60 minutes to allow the antimicrobial concentration to equilibrate in the CSF before opening the drain 3)
● Expert opinion: wait at least 7–10 days after the CSF cultures become sterile to implant a shunt if needed.
Prospective collected multicenter studies
The objective of a study of Lakomkin et al. of the Mount Sinai Hospital, was to determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement.
This was an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection.
A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection.
These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection. 4).
Retrospective cohort studies
Medical records were reviewed for IT/IVT antibiotherapy. Gram-negative nosocomial meningitis cases treated with IT/IVT antibiotherapy additional to systemic antibiotics were included. All patients’ sex, age, SOFA scores, surgical history, cerebrospinal fluid (CSF) culture results, CSF cell counts, systemic and IT/IVT antibiotics, their dosages and duration, CSF culture sterility and sterility time, 28-day mortality due to meningitis, and all other causes were recorded and analyzed.
Results: Thirteen patients were included between 2014 and 2018. The most common microorganism was Acinetobacter baumannii (A.baumannii) (8/13). IT/IVT antibiotics were chosen according to susceptibility. Colistin was used in eight patients, amikacin was used in four, and one patient used amikacin and colistin consecutively. Culture negativity could not be achieved in two patients. Eight patients clinically improved but five patients had no clinical response. 28-day mortality due to infection occured in 2 of 13 patients (15%). 28-day all-cause mortality occured in 3 of 13 patients (23%).
Conclusion: In our study, CSF culture negativity rate was high. IT/IVT antibiotic therapy should be considered as an effective and acceptable treatment option, especially in patients who do not respond to standard IV antibiotherapy 5).
A retrospective cohort study was conducted on patients admitted to intensive care units who received IVT antibiotic treatment at participating centers in the USA between January 01, 2003, and December 31, 2013. Clinical and laboratory parameters, microbiology, surgical and antimicrobial management, and treatment outcomes were collected and described.
Results: Of the 105 patients included, all received systemic antimicrobial therapy along with at least one dose of IVT antimicrobial agents. Intraventricular vancomycin was used in 52.4% of patients. The average dose was 12.2 mg/day for a median duration of 5 days. Intraventricular aminoglycosides were used in 47.5% of the patients, either alone or in combination with IVT vancomycin. The average dose of gentamicin/tobramycin was 6.7 mg/day with a median duration of 6 days. Overall mortality was 18.1%. Cerebrospinal fluid (CSF) culture sterilization occurred in 88.4% of the patients with a rate of recurrence or persistence of positive cultures of 9.5%.
Conclusion: Intraventricular antimicrobial agents resulted in a high CSF sterilization rate. Contemporary use of this route typically results in a treatment duration of less than a week. Prospective studies are needed to establish the optimal patient population, as well as the efficacy and safety of this route of administration 6).