Healthcare-Acquired Meningitis and Ventriculitis

  • Adarsh BhimrajEmail author


Healthcare-associated meningitis and ventriculitis are infections that complicate craniotomies, CSF shunt, and drain surgeries. They are distinct clinical entities compared to community-acquired meningitis. Gram-positive cocci like Staphylococcus epidermidis and S. aureus are the most common pathogens, followed by Gram-negative rods and anaerobes like P. acnes. The diagnosis can be elusive as other noninfectious neurologic conditions and neurosurgeries can cause similar clinical and CSF findings. The management of these infections often requires surgical interventions and may need intraventricular or intrathecal administration of antimicrobials, as the organisms can be refractory to IV antimicrobials alone. Periprocedural antimicrobials and antimicrobial impregnated catheters have been shown to reduce infection rates.


Meningitis Ventriculitis VP shunt infections External ventricular drain (EVD) infections Ventriculostomy-related infections (VRI) Craniotomy-related infections Intraventricular antibiotics Intrathecal antibiotics Central nervous system (CNS) infections Antimicrobial-impregnated catheters 


  1. 1.
    Tunkel A, Drake J. Cerebrospinal fluid shunt infections. In: Mandell G, Bennett J, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2009. p. –6.Google Scholar
  2. 2.
    Arnell K, Cesarini K, Lagerqvist-Widh A, Wester T, Sjolin J. Cerebrospinal fluid shunt infections in children over a 13-year period: anaerobic cultures and comparison of clinical signs of infection with Propionibacterium acnes and with other bacteria. J Neurosurg Pediatr. 2008;1(5):366–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly Jr ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2008;62 Suppl 2:688–700.PubMedGoogle Scholar
  4. 4.
    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(4):468–73.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Snowden JN, Beaver M, Smeltzer MS, Kielian T. Biofilm-infected intracerebroventricular shunts elicit inflammation within the central nervous system. Infect Immun. 2012;80(9):3206–14.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Braxton Jr EE, Ehrlich GD, Hall-Stoodley L, et al. Role of biofilms in neurosurgical device-related infections. Neurosurg Rev. 2005;28(4):249–55.PubMedCrossRefGoogle Scholar
  7. 7.
    Wang KW, Chang WN, Shih TY, et al. Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis. 2004;57(2):44–8.PubMedGoogle Scholar
  8. 8.
    Sells CJ, Shurtleff DB, Loeser JD. Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics. 1977;59(4):614–8.PubMedGoogle Scholar
  9. 9.
    Brook I. Meningitis and shunt infection caused by anaerobic bacteria in children. Pediatr Neurol. 2002;26(2):99–105.PubMedCrossRefGoogle Scholar
  10. 10.
    Rekate HL, Ruch T, Nulsen FE. Diphtheroid infections of cerebrospinal fluid shunts. The changing pattern of shunt infection in Cleveland. J Neurosurg. 1980;52(4):553–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Nisbet M, Briggs S, Ellis-Pegler R, Thomas M, Holland D. Propionibacterium acnes: an under-appreciated cause of post-neurosurgical infection. J Antimicrob Chemother. 2007;60(5):1097–103.PubMedCrossRefGoogle Scholar
  12. 12.
    O’Brien D, Stevens NT, Lim CH, et al. Candida infection of the central nervous system following neurosurgery: a 12-year review. Acta Neurochir (Wien). 2011;153(6):1347–50.PubMedCrossRefGoogle Scholar
  13. 13.
    Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis. 2008;47(1):73–82.PubMedCrossRefGoogle Scholar
  14. 14.
    Moores LE, Ellenbogen RG. Cerebrospinal fluid shunt infections. In: Hall WA, McCutcheon IE, AANS Publications Committee, editors. Infections in neurosurgery. Park Ridge, IL: American Assowwciation of Neurological Surgeons; 2000. p. –53.Google Scholar
  15. 15.
    Rabinstein AA, Sandhu K. Non-infectious fever in the neurological intensive care unit: incidence, causes and predictors. J Neurol Neurosurg Psychiatry. 2007;78(11):1278–80.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Berger C, Schwarz S, Schaebitz WR, Aschoff A, Schwab S. Serum procalcitonin in cerebral ventriculitis. Crit Care Med. 2002;30(8):1778–81.PubMedCrossRefGoogle Scholar
  17. 17.
    Martinez R, Gaul C, Buchfelder M, Erbguth F, Tschaikowsky K. Serum procalcitonin monitoring for differential diagnosis of ventriculitis in adult intensive care patients. Intensive Care Med. 2002;28(2):208–10.PubMedCrossRefGoogle Scholar
  18. 18.
    Schuhmann MU, Ostrowski KR, Draper EJ, et al. The value of C-reactive protein in the management of shunt infections. J Neurosurg. 2005;103(3 Suppl):223–30.PubMedGoogle Scholar
  19. 19.
    Schade RP, Schinkel J, Roelandse FW, et al. Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. J Neurosurg. 2006;104(1):101–8.PubMedCrossRefGoogle Scholar
  20. 20.
    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(7):929–32.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Pfausler B, Beer R, Engelhardt K, Kemmler G, Mohsenipour I, Schmutzhard E. Cell index – a new parameter for the early diagnosis of ventriculostomy (external ventricular drainage)-related ventriculitis in patients with intraventricular hemorrhage? Acta Neurochir (Wien). 2004;146(5):477–81.CrossRefGoogle Scholar
  22. 22.
    Lan CC, Wong TT, Chen SJ, Liang ML, Tang RB. Early diagnosis of ventriculoperitoneal shunt infections and malfunctions in children with hydrocephalus. J Microbiol Immunol Infect. 2003;36(1):47–50.PubMedGoogle Scholar
  23. 23.
    Forgacs P, Geyer CA, Freidberg SR. Characterization of chemical meningitis after neurological surgery. Clin Infect Dis. 2001;32(2):179–85.PubMedCrossRefGoogle Scholar
  24. 24.
    Desai A, Lollis SS, Missios S, et al. How long should cerebrospinal fluid cultures be held to detect shunt infections? Clinical article. J Neurosurg Pediatr. 2009;4(2):184–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Noetzel MJ, Baker RP. Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg. 1984;61(2):328–32.PubMedCrossRefGoogle Scholar
  26. 26.
    Banks JT, Bharara S, Tubbs RS, et al. Polymerase chain reaction for the rapid detection of cerebrospinal fluid shunt or ventriculostomy infections. Neurosurgery. 2005;57(6):1237–43; discussion 1237–43.PubMedCrossRefGoogle Scholar
  27. 27.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly Jr ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2002;51(1):170–81; discussion 181–82.PubMedCrossRefGoogle Scholar
  28. 28.
    Lodise TP, Nau R, Kinzig M, Drusano GL, Jones RN, Sorgel F. Pharmacodynamics of ceftazidime and meropenem in cerebrospinal fluid: results of population pharmacokinetic modelling and Monte Carlo simulation. J Antimicrob Chemother. 2007;60(5):1038–44.PubMedCrossRefGoogle Scholar
  29. 29.
    Lodise Jr TP, Rhoney DH, Tam VH, McKinnon PS, Drusano GL. Pharmacodynamic profiling of cefepime in plasma and cerebrospinal fluid of hospitalized patients with external ventriculostomies. Diagn Microbiol Infect Dis. 2006;54(3):223–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Nau R, Prange HW, Kinzig M, et al. Cerebrospinal fluid ceftazidime kinetics in patients with external ventriculostomies. Antimicrob Agents Chemother. 1996;40(3):763–6.PubMedCentralPubMedGoogle Scholar
  31. 31.
    Ricard JD, Wolff M, Lacherade JC, et al. Levels of vancomycin in cerebrospinal fluid of adult patients receiving adjunctive corticosteroids to treat pneumococcal meningitis: a prospective multicenter observational study. Clin Infect Dis. 2007;44(2):250–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Wang JH, Lin PC, Chou CH, et al. Intraventricular antimicrobial therapy in postneurosurgical Gram-negative bacillary meningitis or ventriculitis: A hospital-based retrospective study. J Microbiol Immunol Infect. 2012. pii: S1684-1182(12)00204-6. doi:  10.1016/j.jmii.2012.08.028. [Epub ahead of print]
  33. 33.
    Wilkie MD, Hanson MF, Statham PF, Brennan PM. Infections of cerebrospinal fluid diversion devices in adults: the role of intraventricular antimicrobial therapy. J Infect. 2013;66(3):239–46.PubMedCrossRefGoogle Scholar
  34. 34.
    Ng K, Mabasa VH, Chow I, Ensom MH. Systematic review of efficacy, pharmacokinetics, and administration of intraventricular vancomycin in adults. Neurocrit Care. 2014;20(1):158–71. doi:  10.1007/s12028-012-9784-z.
  35. 35.
    Tangden T, Enblad P, Ullberg M, Sjolin J. Neurosurgical gram-negative bacillary ventriculitis and meningitis: a retrospective study evaluating the efficacy of intraventricular gentamicin therapy in 31 consecutive cases. Clin Infect Dis. 2011;52(11):1310–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Imberti R, Cusato M, Accetta G, et al. Pharmacokinetics of colistin in cerebrospinal fluid after intraventricular administration of colistin methanesulfonate. Antimicrob Agents Chemother. 2012;56(8):4416–21.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Ziai WC, Lewin 3rd JJ. Improving the role of intraventricular antimicrobial agents in the management of meningitis. Curr Opin Neurol. 2009;22(3):277–82.PubMedCrossRefGoogle Scholar
  38. 38.
    Remes F, Tomas R, Jindrak V, Vanis V, Setlik M. Intraventricular and lumbar intrathecal administration of antibiotics in postneurosurgical patients with meningitis and/or ventriculitis in a serious clinical state. J Neurosurg. 2013;119(6):1596–602. doi:  10.3171/2013.6.JNS122126. Epub 2013 Aug 16.
  39. 39.
    Shah SS, Ohlsson A, Shah VS. Intraventricular antibiotics for bacterial meningitis in neonates. Cochrane Database Syst Rev. 2012;(7):CD004496.Google Scholar
  40. 40.
    Cook AM, Mieure KD, Owen RD, Pesaturo AB, Hatton J. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009;29(7):832–45.PubMedCrossRefGoogle Scholar
  41. 41.
    Brown EM, Edwards RJ, Pople IK. Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery. 2006;58(4):657–65; discussion 657–65.PubMedCrossRefGoogle Scholar
  42. 42.
    The management of neurosurgical patients with postoperative bacterial or aseptic meningitis or external ventricular drain-associated ventriculitis. Infection in Neurosurgery Working Party of the British Society for Antimicrobial Chemotherapy. Br J Neurosurg. 2000;14(1):7–12.Google Scholar
  43. 43.
    Ellner PD, Neu HC. The inhibitory quotient. A method for interpreting minimum inhibitory concentration data. JAMA. 1981;246(14):1575–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267–84.PubMedCrossRefGoogle Scholar
  45. 45.
    Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J. 2002;21(7):632–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Yogev R. Cerebrospinal fluid shunt infections: a personal view. Pediatr Infect Dis. 1985;4(2):113–8.PubMedCrossRefGoogle Scholar
  47. 47.
    James HE, Walsh JW, Wilson HD, Connor JD, Bean JR, Tibbs PA. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery. 1980;7(5):459–63.PubMedCrossRefGoogle Scholar
  48. 48.
    Barker 2nd FG. Efficacy of prophylactic antibiotics against meningitis after craniotomy: a meta-analysis. Neurosurgery. 2007;60(5):887–94; discussion 887–94.PubMedCrossRefGoogle Scholar
  49. 49.
    Korinek AM, Baugnon T, Golmard JL, van Effenterre R, Coriat P, Puybasset L. Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurgery. 2006;59(1):126–33; discussion 126–33.PubMedCrossRefGoogle Scholar
  50. 50.
    Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review. J Neurosurg Pediatr. 2008;1(1):48–56.PubMedCrossRefGoogle Scholar
  51. 51.
    Alleyne Jr CH, Hassan M, Zabramski JM. The efficacy and cost of prophylactic and periprocedural antibiotics in patients with external ventricular drains. Neurosurgery. 2000;47(5):1124–7; discussion 1127–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Poon WS, Ng S, Wai S. CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Acta Neurochir Suppl. 1998;71:146–8.PubMedGoogle Scholar
  53. 53.
    Sonabend AM, Korenfeld Y, Crisman C, Badjatia N, Mayer SA, Connolly Jr ES. Prevention of ventriculostomy-related infections with prophylactic antibiotics and antibiotic-coated external ventricular drains: a systematic review. Neurosurgery. 2011;68(4):996–1005.PubMedGoogle Scholar
  54. 54.
    Thomas R, Lee S, Patole S, Rao S. Antibiotic-impregnated catheters for the prevention of CSF shunt infections: a systematic review and meta-analysis. Br J Neurosurg. 2012;26(2):175–84.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Section of Neurologic Infectious Diseases, Department of Infectious DiseasesCleveland Clinic FoundationClevelandUSA

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