Ventriculostomy related infection risk factors

Ventriculostomy related infection risk factors

A total of 15 supposed influencing factors includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex 1).


In a large series of patients, ventriculostomy related infection (VRI) was associated with a longer ICU stay, but its presence did not influence survival. A longer duration of ventriculostomy catheter monitoring in patients with VRI might be due to an increased volume of drained CSF during infection. Risk factors associated with VRIs are SAH, IVH, craniotomy, and coinfection 2).


A retrospective cohort study strengthens a growing body of works suggesting the importance of inoculation of skin flora as a critical risk factor in ventriculostomy related infections, underscoring the importance of drain changes only when clinically indicated and, that as soon as clinically permitted, catheters should be removed 3).


Associated with a longer ICU stay, but its presence did not influence survival. A longer duration of ventriculostomy catheter monitoring in patients with VAI might be due to an increased volume of drained CSF during infection. Risk factors associated with VAIs are subarachnoid hemorrhage(SAH), intraventricular hemorrhage IVH, craniotomy, and coinfection 4).

The risk of infection increases with increasing duration of catheterization and with repeated insertions. The use of local antibiotic irrigation or systemic antibiotics does not appear to reduce the risk of VAI. Routine surveillance cultures of CSF were no more likely to detect infection than cultures obtained when clinically indicated. These findings need to be considered in infection control policies addressing this important issue 5).


An increased risk of infection has been observed in patients with subarachnoid or intraventricular hemorrhage, in patients with concurrent systemic infections as well as with longer duration of catheterization, cerebrospinal (CSF) leakage, and frequent manipulation of the EVD system 6) 7) 8).

Many studies have been conducted to identify risk factors of EVD-related infections. However, none of these risk factors could be confirmed in a cohort of patients. Furthermore they not show any difference in infection rates between patients who were placed in single- or multibed rooms, respectively 9).


Interestingly no risk factor for EVD-related infection could be identified in a retrospective single center study 10).

References

1)

Sorinola A, Buki A, Sandor J, Czeiter E. Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies. Front Neurol. 2019 Mar 15;10:226. doi: 10.3389/fneur.2019.00226. eCollection 2019. Review. PubMed PMID: 30930840; PubMed Central PMCID: PMC6428739.
2)

Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL. Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg. 2005 Sep;103(3):468-72. PubMed PMID: 16235679.
3)

Katzir M, Lefkowitz JJ, Ben-Reuven D, Fuchs SJ, Hussein K, Sviri G. Decreasing external ventricular drain related infection rates with duration-independent, clinically indicated criteria for drain revision: A retrospective study. World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32121-7. doi: 10.1016/j.wneu.2019.07.205. [Epub ahead of print] PubMed PMID: 31382072.
4)

Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL. Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg. 2005 Sep;103(3):468-72. PubMed PMID: 16235679.
5)

Arabi Y, Memish ZA, Balkhy HH, Francis C, Ferayan A, Al Shimemeri A, Almuneef MA. Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control. 2005 Apr;33(3):137-43. PubMed PMID: 15798667.
6)

Camacho E. F., Boszczowski Í., Basso M., Jeng B. C. P., Freire M. P., Guimarães T., Teixeira M. J., Costa S. F. Infection rate and risk factors associated with infections related to external ventricular drain. Infection. 2011;39(1):47–51. doi: 10.1007/s15010-010-0073-5.
7)

Kim J.-H., Desai N. S., Ricci J., Stieg P. E., Rosengart A. J., Hrtl R., Fraser J. F. Factors contributing to ventriculostomy infection. World Neurosurgery. 2012;77(1):135–140. doi: 10.1016/j.wneu.2011.04.017.
8)

Mayhall C. G., Archer N. H., Lamb V. A., Spadora A. C., Baggett J. W., Ward J. D., Narayan R. K. Ventriculostomy-related infections. A positive epidemiologic study. The New England Journal of Medicine. 1984;310(9):553–559. doi: 10.1056/NEJM198403013100903.
9)

Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C. External Ventricular Drain Infections: Risk Factors and Outcome. Interdiscip Perspect Infect Dis. 2014;2014:708531. Epub 2014 Nov 17. PubMed PMID: 25484896; PubMed Central PMCID: PMC4251652.
10)

Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C. External ventricular drain infections: risk factors and outcome. Interdiscip Perspect Infect Dis. 2014;2014:708531. doi: 10.1155/2014/708531. Epub 2014 Nov 17. PubMed PMID: 25484896; PubMed Central PMCID: PMC4251652.

Neurapheresis

Neurapheresis

http://www.neurapheresis.org

The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products.


It has been hypothesized that early and rapid filtration of blood from cerebrospinal fluid (CSF) in post-subarachnoid hemorrhage patients may reduce hospital stay and related adverse events.

Khani et al. formulated a subject-specific computational fluid dynamics (CFD) model to parametrically investigate the impact of a novel dual-lumen catheter-based CSF filtration system, the NeurapheresisTM system (Minnetronix Neuro, Inc., St. Paul, MN), on intrathecal CSF dynamics. The operating principle of this system is to remove CSF from one location along the spine (aspiration port), externally filter the CSF routing the retentate to a waste bag, and return permeates (uncontaminated CSF) to another location along the spine (return port). The CFD model allowed parametric simulation of how the Neurapheresis system impacts intrathecal CSF velocities and steady-steady streaming under various Neurapheresis flow settings ranging from 0.5 to 2.0 ml/min and with a constant retentate removal rate of 0.2 ml/min. simulation of the Neurapheresis system was compared to a lumbar drain simulation with a typical CSF removal rate setting of 0.2 ml/min. Results showed that the Neurapheresis system at a maximum flow of 2.0 ml/min increased average steady-streaming CSF velocity 2X in comparison to lumbar drain (0.190 ± 0.133 versus 0.093 ± 0.107 mm/s, respectively). This effect was localized to the region within the Neurapheresis flow-loop. The mean velocities introduced by the flow-loop were relatively small in comparison to normal cardiac-induced CSF velocities 1).


It is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device.

A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery.

Safety of the Neurapheresis procedure was confirmed in this first case, and it will continue to evaluate the safety of the Neurapheresis system through the PILLAR trial 2).


Smilnak et al., provided the first publication demonstrating the direct ability to rapidly clear, both in vitro and in vivo, the otherwise slowly removed fungal pathogen that directly contributes to the morbidity and mortality seen in Cryptococcal Meningitis (CM) 3).

References

1)

Khani M, Sass L, McCabe A, Zitella Verbick L, Lad SP, Sharp MK, Martin B. Impact of Neurapheresis system on intrathecal cerebrospinal fluid dynamics: a computational fluid dynamics study. J Biomech Eng. 2019 Jul 25. doi: 10.1115/1.4044308. [Epub ahead of print] PubMed PMID: 31343659.
2)

Blackburn SL, Swisher CB, Grande AW, Rubi A, Verbick LZ, McCabe A, Lad SP. Novel Dual Lumen Catheter and Filtration Device for Removal of Subarachnoid hemorrhage: First Case Report. Oper Neurosurg (Hagerstown). 2018 Jun 5. doi: 10.1093/ons/opy151. [Epub ahead of print] PubMed PMID: 29873785.
3)

Smilnak GJ, Charalambous LT, Cutshaw D, Premji AM, Giamberardino CD, Ballard CG, Bartuska AP, Ejikeme TU, Sheng H, Verbick LZ, Hedstrom BA, Pagadala PC, McCabe AR, Perfect JR, Lad SP. Novel Treatment of Cryptococcal Meningitis via Neurapheresis Therapy. J Infect Dis. 2018 Aug 24;218(7):1147-1154. doi: 10.1093/infdis/jiy286. PubMed PMID: 29788431; PubMed Central PMCID: PMC6107745.

Infectious aneurysm

Infectious aneurysm

Infectious aneurysm (also known as mycotic aneurysm or microbial arteritis) is an aneurysm arising from bacterial infection of the arterial wall. It can be a common complicationof the hematogenous spread of bacterial infection.

William Osler first used the term “mycotic aneurysm” in 1885to describe a mushroom-shaped aneurysm in a patient with subacute bacterial endocarditis 1). rather than the current usage which infers a fungal etiology. Currently accepted terminology favors infectious aneurysm (or bacterial aneurysm). Infectious aneurysms can, however, also occur with fungal infections 2).

However, mycotic aneurysm is still used for all extracardiac or intracardiac aneurysms caused by infections, except for syphilitic aortitis.

The term “infected aneurysm,” proposed by Jarrett and associates is more appropriate, since few infections involve fungi.

According to some authors, a more accurate term might have been endovascular infection or infective vasculitis, because mycotic aneurysms are not due to a fungal organism.

Epidemiology

1. comprise ≈ 4% of intracranial aneurysms.

2. Intracranial mycotic aneurysms (ICMAs) complicate about 2% to 3% of infective endocarditis (IE) cases, although as many as 15% to 29% of patients with IE have neurologic symptoms.

3. most common location: distal middle cerebral artery branches (75–80%)

4. at least 20% have or develop multiple intracranial aneurysms

5. increased frequency in immunocompromised patients (e.g. AIDS) and drug users

6. most probably start in the adventitia (outer layer) and spread inward


Left ventricular assist device-associated subarachnoid hemorrhage may be caused by infectious intracranial aneurysms when acute bloodstream infections are present 3).

Pathogens

streptococcus– 44% – S. viridans (classic cause of SBE)

staphylococcus– 18% S. aureus (cause of acute bacterial endocarditis)

miscellaneous – 6% (pseudomonasenterococcus, corynebacteria…)

multiple 5%

no growth 12%

no info 14%

total 99% 4).

Diagnosis

Blood cultures and LP may identify the infectious organism. Patients with suspected infectious aneurysm(s) should undergo echocardiography to look for signs of endocarditis.

Treatment

For the clinician, early diagnosis is the cornerstone of effective treatment. Without medical or surgical management, catastrophic hemorrhage or uncontrolled sepsis may occur. However, symptomatology is frequently nonspecific during the early stages, so a high index of suspicion is required to make the diagnosis.


These aneurysms usually have fusiform morphology and are usually very friable, therefore surgical treatment is difficult and/or risky. Most cases are treated acutely with antibiotics which are continued 4–6 weeks. Serial angiography (at 7–10 days and 1.5, 3, 6 and 12 months, even if aneurysms seem to be getting smaller, they may subsequently increase 5) and new ones may form) helps document the effectiveness of medical therapy (serial MRA may be a viable alternative in some cases). Aneurysms may continue to shrink following completion of antibiotic therapy 6). Delayed clipping may be more feasible; indications include:

1. patients with SAH.

2. increasing size of an aneurysm while on antibiotics (controversial, some say not mandatory) 7).

3. failure of the aneurysm to reduce in size after 4–6 weeks of antibiotics 8).

Patients with subacute bacterial endocarditis requiring valve replacement should have bioprosthetic (i.e. tissue) valves instead of mechanical valves to eliminate the need for risky anticoagulation.

Case reports

Lee et al. reported three left ventricular assist device recipients who presented with septicemia and developed subarachnoid hemorrhage. Case 1, a 37-year-old male with non-ischemic cardiomyopathy with HeartMate II, presented with confusion and found to have Serratia bloodstream infection and left frontal lobe subarachnoid hemorrhage. A cerebral angiography showed a right M3/M4 branch infectious intracranial aneurysm. He was treated with coil embolization and underwent device exchange. Case 2, a 41-year-old male with non-ischemic cardiomyopathy with HeartMate II presented with confusion and found to have methicillin-resistant staphylococcus aureus bloodstream infection and bilateral frontal convexity subarachnoid hemorrhage. Cerebral angiogram showed left M3 and left A3 infectious intracranial aneurysms, which were treated with antibiotics alone. Case 3, a 58-year-old female with ischemic cardiomyopathy with HeartMate II presented with fever, found to have candida albicans bloodstream infection and a parieto-occipital enhancing lesion concerning for cerebral abscess. Repeat computed tomography brain a week later showed a new right frontal subarachnoid hemorrhage. Cerebral angiogram showed a M4/M5 junction infectious intracranial aneurysm; patient was not a surgical candidate and was transitioned to hospice. This case series emphasizes that left ventricular assist device-associated subarachnoid hemorrhage may be caused by infectious intracranial aneurysms when acute bloodstream infections are present 9).


Khan et al.reported two cases of a ruptured mycotic aneurysm with intracerebral hematoma and impending brain herniation. Both patients had signs of high intracranial pressure and required urgent surgical evacuation of a clot. One patient survived while the other patient expired soon after surgery.

Mycotic aneurysm of middle cerebral artery (MCA) in IE with intracranial hemorrhage is rare and urgent surgical decompression, and aneurysmal clipping can be lifesaving 10).

References

1)

Bohmfalk GL, Story JL, Wissinger JP, et al. Bacterial Intracranial Aneurysm. J Neurosurg. 1978; 48:369–382
2)

Horten BC, Abbott GF, Porro RS. Fungal Aneurysms of Intracranial Vessels. Arch Neurol. 1976; 33:577– 579
3)

Lee T, Buletko AB, Matthew J, Cho SM. Bloodstream infection is associated with subarachnoid hemorrhage and infectious intracranial aneurysm in left ventricular assist device. Perfusion. 2019 Jul 24:267659119858853. doi: 10.1177/0267659119858853. [Epub ahead of print] PubMed PMID: 31339450.
4)

Schmidek HH, Sweet WH. Operative Neurosurgical Techniques. New York 1982
5)

Pootrakul A, Carter LP. Bacterial Intracranial Aneurysm: Importance of Sequential Angiography. Surg Neurol. 1982; 17:429–431
6) , 7)

Morawetz RB, Karp RB. Evolution and Resolution of Intracranial Bacterial (Mycotic) Aneurysms. Neurosurgery. 1984; 15:43–49
8)

Bingham WF. Treatment of Mycotic Intracranial Aneurysms. J Neurosurg. 1977; 46:428–437
9)

Lee T, Buletko AB, Matthew J, Cho SM. Bloodstream infection is associated with subarachnoid hemorrhage and infectious intracranial aneurysm in left ventricular assist device. Perfusion. 2019 Jul 24:267659119858853. doi: 10.1177/0267659119858853. [Epub ahead of print] PubMed PMID: 31339450.
10)

Khan A, Waqas M, Nizamani WM, Bari ME. Ruptured mycotic aneurysms: Report and outcomes of two surgically managed patients. Surg Neurol Int. 2017 Jul 11;8:144. doi: 10.4103/sni.sni_78_17. eCollection 2017. PubMed PMID: 28781921; PubMed Central PMCID: PMC5523478.
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