Intraventricular antibiotic

Intraventricular antibiotic

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).

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.

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).

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).


1)

Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, van de Beek D, Bleck TP, Garton HJL, Zunt JR. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017 Mar 15;64(6):e34-e65. doi: 10.1093/cid/ciw861. PMID: 28203777; PMCID: PMC5848239.
2)

Karvouniaris M, Brotis AG, Tsiamalou P, Fountas KN. The Role of Intraventricular Antibiotics in the Treatment of Nosocomial Ventriculitis/Meningitis from Gram-Negative Pathogens: A Systematic Review and Meta-Analysis. World Neurosurg. 2018 Dec;120:e637-e650. doi: 10.1016/j.wneu.2018.08.138. Epub 2018 Aug 29. PMID: 30172065.
3)

Cook AM, Mieure KD, Owen RD, et al. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009; 29:832–845
4)

Lakomkin N, Hadjipanayis CG. The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement. Neurosurgery. 2021 Jan 13;88(2):301-305. doi: 10.1093/neuros/nyaa413. PMID: 32985657.
5)

Ayhan M, Kaya Kalem A, Hasanoglu İ, Kayaaslan B, Ozates MO, İzdes S, Halacli B, Guner HR. Intrathecal and intraventricular administration of antibiotics in gram-negative nosocomial meningitis in a research hospital in Turkey. Turk Neurosurg. 2020 Jun 25. doi: 10.5137/1019-5149.JTN.29844-20.2. Epub ahead of print. PMID: 33575996.
6)

Lewin JJ 3rd, Cook AM, Gonzales C, Merola D, Neyens R, Peppard WJ, Brophy GM, Kurczewski L, Giarratano M, Makii J, Rowe AS, Tesoro EP, Zaniewski A, Clark S, Ziai WC. Current Practices of Intraventricular Antibiotic Therapy in the Treatment of Meningitis and Ventriculitis: Results from a Multicenter Retrospective Cohort Study. Neurocrit Care. 2019 Jun;30(3):609-616. doi: 10.1007/s12028-018-0647-0. PMID: 30446934.

May 2, Webinar Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

IFNE/ WFNS Endoscopy Weekend Update 3
Topic: Endoscopic Ant Fossa Meningioma Excision/ Intraventricular Tumor Management

Time: May 2, 2020
08:00 AM (Ohio GMT -4)
02:00 PM (Italy GMT +2)
12:00 PM (GMT +0)
05:00 PM (Pakistan Time GMT +5)

Join Zoom Meeting
https://zoom.us/j/93802030387
Meeting ID: 938 0203 0387

Intraventricular ganglioglioma

see also Third ventricle ganglioglioma.

Involvement of the ventricular system is rare.

Clinical features

The symptoms are intracranial hypertension or seizure. The degree of hydrocephalus is closely related to the site of tumor’s basement 1).

Outcome

The prognosis is good after total resection. The patients with GTR should be followed-up 2).

Diagnosis

The review of 25 previously reported intraventricular gangliogliomas found that their pre-surgical diagnoses were often incorrect, reflecting the difficulty of making the diagnosis with signs, symptoms, and imaging alone 3).

http://aws.labome.com/figure/te-651-2.png

(A) Coronal T1-weighted image and (B) Axial T2-weighted image showing a solid-cystic intraventricular lesion in the trigone of the right lateral ventricle. The solid component was isointense, and heterogeneous contrast enhancement was observed. Additionally, (C) Axial T1-weighted image showing lobulated isointense lesion in the optic chiasm.

Case series

A total of 7 cases with intraventricular ganglioglioma diagnosed by the surgical pathology examination from June 2004 to April 2011 in our center were retrospectively analyzed. The clinical data were collected from the clinical medical records, and the tumor site, size and basement of tumor were analyzed. Follow up was performed to obtain the clinical outcomes.

The 7 cases included 5 males and 2 females, with disease onset at 23.6 ± 14.9 years old. Epilepsy as the initial symptom was observed in 1 case. Reduced hearing, dizziness and weakness of both lower limbs were found in 1 case. Intracranial hypertension were detected in 5 cases, including 1 case complicating by decreased visual acuity. Tumors were located in the lateral ventricle in 5 cases, while 2 cases in the third ventricle. Hydrocephalus was observed in 5 cases, including 2 cases with severe hydrocephalus, and both underwent ventriculoperitoneal shunting. Total resection of tumors was performed in 5 cases, and 2 cases underwent gross total resection. The mean duration of follow-up was 28.7 months (8-90 months). Intracranial hypertension in all cases disappeared. Even radiotherapy post-surgery, one case with GTR relapsed 1 year later. However, the other 6 cases didn’t relapse.

Ganglioglioma in ventricular system is extremely rare, mainly with the symptoms of intracranial hypertension or seizure. The degree of hydrocephalus is closely related to the site of tumor’s basement. The prognosis is good after total resection. The patients with GTR should be followed-up 4).

Case reports

Chatrath et al., from the University of Virginia School of MedicineBethesdaMD Anderson Cancer Center Houston, report a case of an intraventricular ganglioglioma involving the septum pellucidum in a pediatric patient with history of optic glioma. Only one other pediatric intraventricular ganglioglioma arising from the septum pellucidum has been reported previously.

The patient initially presented at 9 months of age with a pilocytic astrocytoma centered on the optic chiasm, treated with chemotherapy and radiation at 3 years of age. Routine follow-up imaging at 13 years of age revealed the development of a mass in the septum pellucidum, which was subtotally resected endoscopically because of its proximity to the fornices. Pathology confirmed a ganglioglioma positive for the BRAF V600Emutation. The tumor residual progressed and was treated with stereotactic radiosurgery. The patient was asymptomatic at her 6-month follow-up visit and the size of the nodule remained stable.

The review of the 25 previously reported intraventricular gangliogliomas found that their pre-surgical diagnoses were often incorrect, reflecting the difficulty of making the diagnosis with signs, symptoms, and imaging alone. Patients can be reassured that the prognosis is generally favorable following uncomplicated neurosurgical resection 5).


Samdani et al., from the Shriners Hospital for Children, described an illustrative case of an intraventricular ganglioglioma with a prominent cystic component and enhancing mural nodule, which represents the classic radiographic appearance of gangliogliomas described in other locations. A superior parietal lobule approach offered excellent surgical access for tumor removal and the patient has remained free of neurological deficits following surgery. Regardless of location within the central nervous system, ganglioglioma should be on the differential diagnosis for any cystic mass with a mural nodule, particularly in the setting of epilepsy 6).


A patient with a ganglioglioma is presented in the previously unreported location of the anterior third ventricle at the foramen of Monro, mimicking a colloid cyst. We review all other reported cases of intraventricular ganglioglioma (n=6) to characterize this entity. Intraventricular gangliogliomas typically affect younger patients with female predominance (male:female, 2:5; median age 25 years). Symptoms occur secondary to obstruction of physiological cerebrospinal fluid circulation. Complete surgical resection with re-establishment of cerebrospinal fluid drainage is the goal of treatment 7).

References

1) , 2) , 4)

Deling L, Nan J, Yongji T, Shuqing Y, Zhixian G, Jisheng W, Liwei Z. Intraventricular ganglioglioma prognosis and hydrocephalus: the largest case series and systematic literature review. Acta Neurochir (Wien). 2013 Jul;155(7):1253-60. doi: 10.1007/s00701-013-1728-7. Epub 2013 May 3. PubMed PMID: 23640526.
3) , 5)

Chatrath A, Mastorakos P, Mehta GU, Wildeman M, Moosa S, Jane JA Jr. Ganglioglioma Arising from the Septum Pellucidum: Case Report and Review of the Literature. Pediatr Neurosurg. 2019 Jan 8:1-10. doi: 10.1159/000495043. [Epub ahead of print] PubMed PMID: 30620941.
6)

Samdani AF, Torre-Healy A, Khalessi A, McGirt M, Jallo GI, Carson B. Intraventricular ganglioglioma: a short illustrated review. Acta Neurochir (Wien). 2009 Jun;151(6):635-40. doi: 10.1007/s00701-009-0246-0. Epub 2009 Mar 17. Review. PubMed PMID: 19290468.
7)

Hauck EF, Vu L, Campbell GA, Nauta HJ. Intraventricular ganglioglioma. J Clin Neurosci. 2008 Nov;15(11):1291-3. doi: 10.1016/j.jocn.2007.09.013. Epub 2008 Oct 1. Review. PubMed PMID: 18829326.
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