Infecciones del sistema nervioso central asociadas a dispositivos de derivación de LCR en niños, en un centro neuro-quirúrgico de referencia nacional / Central nervous system infections associated with CSF shunt devices in children, at a national reference hospital

INTRODUCCIÓN: Las infecciones asociadas a dispositivos de derivación de LCR son una complicación frecuente en su utilización. Lo más habitual es la presencia de cocáceas grampositivas, como Staphylococcus coagulasa negativa (50% en algunas series) y Staphylococcus aureus. Esta complicación agrega morbimortalidad al paciente neuroquirúrgico, aumentando la estadía hospitalaria y los costos de tratamiento. OBJETIVO: Conocer la incidencia de infecciones asociadas a dispositivos de derivación de LCR en un centro de referencia nacional. METODOLOGÍA: Estudio descriptivo, retrospectivo. Se recolectó la información de los pacientes pediátricos (bajo 18 años) entre 2018 y 2019. Se realizó un análisis estadístico descriptivo e inferencial utilizando el lenguaje estadístico R 3.4.0 y RStudio 1.3.9. Se calculó la incidencia acumulada para cada procedimiento, evaluando si existe diferencias significativas entre ellas. Estudio aprobado por el Comité de Ética Pediátrico del SSMO. RESULTADOS: En el período estudiado se realizaron 175 cirugías. Encontramos 19 casos de ventriculitis asociada a derivativa ventriculo-peritoneal y 7 casos en derivativa ventricular-externa. Los agentes más frecuentes fueron las cocáceas grampositivas. No se logró identificar factores de riesgo significativos.

BACKGROUND: Infections associated with CSF shunt devices are a frequent complication in their use. The most common is the presence of gram positive coccaceae, such as coagulase negative Staphylococcus (50% in some series) and Staphylococcus aureus. This complication adds morbidity and mortality to the neurosurgical patient, increasing hospital stay and treatment costs. AIM: To determine the incidence of infections associated with CSF shunt devices in a national referral center. METHODS: Retrospective, descriptive study. Information was collected on pediatric patients between 2018 and 2019. A descriptive and inferential statistical analysis was performed using the statistical language R 3.4.0 and RStudio 1.3.9. The cumulative incidence for each procedure was calculated, evaluating whether there were significant differences between them. This study was approved by the Pediatric Ethics Committee of the SSMO. RESULTS: In the period studied, 175 surgeries were performed. We found 19 cases of ventriculitis associated with ventriculoperitoneal derivative and 7 cases in ventricular-external derivative. The most frequent agents were grampositive coccaceae. It was not possible to identify significant risk factors.

Tratamiento exitoso de la ventriculitis por Acinetobacter baumanii multidrogo resistente con colistina intravenosa e intraventricular / Successful treatment of ventriculitis due to multidrug resistant Acinetobacter baumanii with intravenous and intraventricular colistin

RESUMEN Las infecciones del sistema nervioso central asociadas a dispositivos como el drenaje ventricular externo son frecuentes. Sin embargo, la ventriculitis por bacterias Gram negativas y resistentes a antibióticos genera un reto para el tratamiento médico y quirúrgico. Se presenta el caso de un paciente con diagnóstico de malformación arteriovenosa rota con hemorragia intraventricular que requirió la colocación de un dren ventricular externo. En la evolución posterior, desarrolló ventriculitis por Acinetobacter baumanii multidrogo resistente (MDR) confirmada por cultivos de líquido cefalorraquídeo y se procedió a tratamiento antibiótico dirigido por antibiograma, usando colistina endovenosa e intraventricular asociando meropenem, logrando la normalización de los valores de LCR. Además describimos la evolución clínica, tratamiento médico-quirúrgico y complicaciones asociadas durante su estancia en la unidad de cuidados intensivos.

SUMMARY Central nervous system infections associated with devices such as external ventricular drains are frequent. Ventriculitis due to multi drug resistant (MDR) Gram-negative bacteria represent a surgical and medical challenge. We present the case of a patient who presented with intraventricular hemorrhage due to a rupture of an arteriovenous malformation that needed the insertion of an external ventricular drainage. The patient subsequently developed ventriculitis due to a MDR Acinetobacter baumanii confirmed by isolation from the cerebral spinal fluid (CSF) hat was treated based on the drug susceptibility test with intravenous and intraventricular colistin plus meropenem achieving normalization of the CSF parameters. We report the clinical evolution, complications and medical-surgical treatment in the intensive care unit.

Intraventricular Vancomycin Therapy for Intractable Bacillus cereus Ventriculitis

Bacillus cereus causes serious central nervous system infections, especially in immunocompromised patients. Successful treatment requires adequate antimicrobial concentrations in the cerebrospinal fluid; however, in some cases, achieving this with systemic treatment alone is difficult. We treated intractable B. cereus ventriculitis with intraventricular vancomycin, with no major adverse events.

Neonato con Ventriculitis causada por Empedobacter Brevis: Reporte de un caso en Perú / Neonate with Ventriculitis caused by Empedobacter Brevis: Report of a case in Peru

RESUMEN Las infecciones causadas por microorganismos poco comunes son objeto de investigación, ya que animar a los investigadores a encontrar las medidas sanitarias necesarias para prevenir y tratar la enfermedad, así como la búsqueda de nuevas luces sobre las interacciones humano-microbios. En este informe se describe el caso de un recién nacido varón diagnosticado de hidrocefalia y mielomeningocele, que desarrolló ventriculitis y sepsis por Empedobacter brevis resistente. Este caso pone de manifiesto la inesperada identificación de esta bacteria en el líquido cefalorraquídeo y su patrón multirresistente, que fue crucial para dar un manejo terapéutico adecuado. Esta bacteria evidencia una mezcla de diferentes etiologías en el análisis del líquido cefalorraquídeo.

ABSTRACT Infections caused by rare micro-organisms are the subject of research, as researchers are encouraged to find the necessary health measures to prevent and treat the disease, as well as the search for new insights into human-microbial interactions. This report describes the case of a newborn boy diagnosed with hydrocephalus and myelomeningocele who developed ventriculitis and sepsis from resistant Empedobacter brevis. This case highlights the unexpected identification of this bacterium in the cerebrospinal fluid and its multi-resistant pattern, which was crucial for proper therapeutic management. This bacterium shows a mixture of different etiologies in the analysis of cerebrospinal fluid.

Infecciones asociadas a sistemas de derivación de líquido cefalorraquídeo en pediatría: análisis epidemiológico y de factores de riesgo de mortalidad / Cerebrospinal fluid shunt-associated infections in pediatrics: Analysis of the epidemiology and mortality risk factors

Introducción. La infección es de las complicaciones más frecuentes de los sistemas de derivación ventricular de líquido cefalorraquídeo. El objetivo fue describir las características clínicas, microbiológicas y evolutivas de niños con infección asociada a sistemas de derivación ventricular de líquido cefalorraquídeo y analizar los factores de riesgo, relacionados con la mortalidad. Población y métodos. Estudio descriptivo, retrospectivo, llevado a cabo en el Hospital "Prof. Dr. Juan P. Garrahan" de la Ciudad de Buenos Aires. Se evaluaron todos los pacientes internados desde el 1/1/2012 y el 31/12/2015 compatibles con ventriculitis y cultivo de líquido cefalorraquídeo positivo. Resultados. Se incluyeron 49 pacientes con 57 infecciones. La mediana de edad fue de 62 meses (rango intercuartílico: 19-114). Predominó el sexo masculino: 34 (70%). El tumor del sistema nervioso central fue la enfermedad de base más frecuente: 20 (40%). Se aisló estafilococo coagulasa negativo en 26 (46%), Staphylococcus aureus en 13 (23%), bacilos Gramnegativos en 11 (19%) y otros en 7 (12%). En 55 (97%) de las infecciones, se realizó tratamiento quirúrgico con retiro del sistema de derivación ventricular más antibioticoterapia. La mortalidad fue del 9%. Los únicos factores asociados a la mortalidad estadísticamente significativos fueron hemocultivos positivos (p= 0,04), fiebre al ingreso (p= 0,04) y shock séptico (p= 0,0006). Conclusiones. El estafilococo coagulasa negativo fue el germen más frecuente. El retiro de la válvula, junto con la antibioticoterapia, fue el tratamiento más utilizado. La presencia de fiebre al ingreso, hemocultivos positivos y shock séptico fueron predictores de mortalidad.

Introduction. Infections are the most common complications of ventricular cerebrospinal fluid shunts. The objective of this study was to describe the clinical, microbiological, and evolutionary characteristics of children with ventricular cerebrospinal fluid shunt-associated infections and analyze the risk factors for mortality. Population and methods. Descriptive, retrospective study carried out at Hospital "Prof. Dr. Juan P. Garrahan" in the Autonomous City of Buenos Aires. All patients hospitalized between January 1st, 2012 and December 31st, 2015 who were compatible with ventriculitis and had a positive cerebrospinal fluid culture were assessed. Results. A total of 49 patients with 57 infections were included. Their median age was 62 months (interquartile range: 19-114). Males predominated: 34 (70%). A central nervous system tumor was the most common underlying disease: 20 (40%). Coagulase-negative Staphylococcus was isolated in 26 (46%); Staphylococcus aureus, in 13 (23%); Gram-negative bacilli, in 11 (19%); and other microorganism, in 7 (12%). Treatment consisted of removal of ventricular shunt plus antibiotic therapy for 55 (97%) infections. The mortality rate was 9%. The only statistically significant factors associated with mortality were positive blood cultures (p= 0.04), fever at the time of admission (p= 0.04), and septic shock (p= 0.0006). Conclusions. Coagulase-negative Staphylococcus was the most common microorganism. Valve removal plus antibiotic therapy was the most frequently instituted treatment. Fever at the time of admission, positive blood cultures, and septic shock were predictors of mortality.

Ventriculitis Associated with Extended Spectrum Beta-Lactamase Producing Klebsiella pneumoniae after Acupuncture

BACKGROUND: Ventriculitis is a rare and critical infection of the central nervous system. Here, we report a case of ventriculitis by extended spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae , after acupuncture at the low back. CASE REPORT: A 72-year-old woman visited our center with fever, headache, and decreased mental status, after undergoing low back acupuncture. Brain imaging showed the fluid-debris level in the lateral ventricle, suggesting ventriculitis. ESBL producing Klebsiella pneumoniae were cultured from the cerebrospinal fluid. After the administration of antibiotics, although the ventriculitis was treated, the quadriplegia remained. CONCLUSIONS: This case stresses the importance of aseptic techniques during acupuncture.

Absceso cerebral complicado con ruptura intraventricular: reporte de dos casos y revisión de la literatura / Intraventricular rupture of brain abscess: report of two cases and review of the literature

El absceso cerebral es una patología infecciosa infrecuente cuyo diagnóstico oportuno y tratamiento adecuado conducen a un buen pronóstico en la mayoría de los casos. La ruptura intraventricular es una complicación rara del absceso cerebral con elevada mortalidad; se caracteriza por compromiso brusco de la conciencia, con aparición de signos de irritación meníngea y hallazgos radiológicos compatibles con un drenaje de secreción purulenta hacia los ventrículos. El tratamiento incluye la administración de antibióticos intravenosos e intratecales asociados a una rápida intervención quirúrgica para drenaje del absceso y del contenido intraventricular. Presentamos dos casos de absceso cerebral complicado con ruptura intraventricular, que mostraron características clínicas y radiológicas propias de esta condición, con evolución favorable solo con tratamiento antibiótico endovenoso durante seis a diez semanas, respectivamente...

Brain abscess is an infrequent infectious disease that has a good prognosis in most of the cases with timely diagnosis and suitable treatment. Intraventricular rupture is a rare complication of the brain abscess with high mortality. It is characterized by a sudden consciousness compromise with signs of meningeal irritation and radiological findings compatible with purulent drainage into the ventricles. Treatment includes administration of intravenous and intrathecal antibiotics associated to prompt surgical intervention to drain the abscess and intraventricular content. Two cases of brain abscess complicated with intraventricular rupture showing clinical and radiological features typical of this condition and favorable outcome with intravenous antibiotic treatment during six and ten weeks respectively are reported...

A Case of Ventriculitis Associated with Renal Abscess Caused by Serotype K1 Klebsiella pneumoniae

Recently, serotype K1 Klebsiella pneumoniae has been a major agent of an invasive syndrome characterized by liver abscess and its metastatic infection. Extrahepatic infection and its characteristics in patients with renal abscess caused by K. pneumoniae are poorly understood, and few cases of central nervous system infection have been reported. This is a report of 80-year-old woman with uncontrolled type 2 diabetes mellitus with renal abscess caused by serotype K1 K. pneumoniae, complicated with ventriculitis despite of appropriate use of antibiotics. Physicians need to be aware of possibility of metastatic infection in patients with serotype K1 K. pneumoniae infection, if they develop neurologic symptom and focus of infection is still present.

Risk factors for infection in external ventricular drains / Fatores de risco para infecção em derivações ventriculares externas

Objective: The present study aims to define the main risk factors for infection in EVD implants performed in a public tertiary hospital in Belo Horizonte, Brazil. Method: The present study performed a retrospective review of 137 cases of EVD implants in 107 patients from January 2006 to December 2008. Of these cases, 25 patients had to be re-operated, totally 141 implanted shunts. Results: Forty-eight (45%) patients were male and 59 (55%) were female. The age ranged from 6 to 86 years of age (52.12 ± 15.51 years). The incidence of EVD-related infection was 32.7%, while the device permanence varied from 2 to 54 days (mean of 10 days). The EVDs that were maintained for more than 9.5 days, as well as the device changes proved to be statistically significant factors for cerebrospinal fluid (CSF) infection (p < 0.001). Antibiotic prophylaxis did not change the infection rate (p = 0.395). Conclusions: Risk factors for EVD infection included a continuing EVD permanence that lasted for more than 9.5 days and device changes. The present study concluded that there is no advantage for antibiotic prophylaxis regarding CSF infection with EVD implants...

Objetivo: Este estudo objetiva avaliar os fatores de risco para infecção em pacientes submetidos a derivações externas em um hospital público terciário de Belo Horizonte. Método: Revisados retrospectivamente 137 prontuários e selecionados 107 pacientes, dos quais 25 foram submetidos a mais de uma DVE, totalizando 141 DVE instaladas no período de janeiro de 2006 a dezembro de 2008. Resultados: Dos 107 pacientes selecionados, 48 (45%) eram do gênero masculino e 59 (55%), do feminino. A idade variou de 6 a 86 anos (média de 52,12 e desvio-padrão de 15,51 anos). Ocorreu infecção em 32,7% dos pacientes (24,8% das DVE ? 35 casos). O número total de dias de DVE variou de 2 a 54 (média de 10 dias) e demonstrou-se que o uso por período maior que 9,5 dias e a troca do sistema apresentaram significância estatística para o desenvolvimento de infecção (p < 0,001). O uso de antibióticos não apresentou efeito protetor (p = 0,395). Conclusões: A troca do sistema e o tempo de permanência da DVE determinaram a ocorrência de infecções, com aumento do risco após o 10º dia de uso e nos pacientes submetidos a duas ou mais DVE. O uso de antibióticos profiláticos não foi significativo para redução de infecção...

Characteristics of Device-Associated Cerebrospinal Fluid Infection in Adults

OBJECTIVE: Device-associated infections in the central nervous system are serious complications of procedures involving indwelling devices among neurosurgical patients. In this study, the clinical characteristics and outcome of microbiologically confirmed device-associated cerebrospinal fluid (CSF) infection were evaluated. METHODS: We performed a retrospective analysis of adult patients found to have a positive CSF culture result during a hospital admission between 1 January 2005 through 2 October 2010 in Soonchunhyang University Hospital. RESULTS: During the study period, all episodes (n=161 CSF specimens, 87 patients) involving a culture-positive CSF were enrolled. Thirty-two episodes of device-associated CSF infection were included in the analysis among the study group. Most device-associated infections were ventriculo-peritoneal shunt infections (14/32, 44%). Fever (>38degrees C) was present in 17 episodes (53%). Overall, the most common microorganism was coagulase-negative staphylococcus (7/32 [22%]). Gram-negative rods (Pseudomonas aeruginosa 6/32 [19%], Acinetobacter baumannii/haemolyticus 5/32 [16%]) were identified in culture in 16/32 (50%). Device was removed for the control of device-associated infection in 30/32 (94%). Cure rate was 69% (22/32). All patients with treatment failure (10/32, 34%) expired. CONCLUSION: It is difficult to diagnosis device-associated CSF infections early since those are frequently presented with nonspecific clinical signs and symptoms. In our study, gram-negative infections accounted for 50% of cases and the empiric antibiotics initially chosen were found to not be effective against the final identified pathogen in many cases. Device-associated CSF infections should be strongly considered a serious risk factor associated with CSF infections, and prompt initiation of broad coverage antibiotics should be started after appropriate assessment.

Brainstem Infarction Complicated by Pneumococcal Ventriculitis / 대한뇌졸중학회지

We report an adult case of pontine infarct complicated by a community-acquired pneumococcal ventriculitis. An 85-year-old woman was referred to the hospital with left-sided weakness and persistent fever despite antibiotics therapy. Diffusion weight magnetic resonance image revealed high signal intensity on the right paramedian pontine and the occipital horn of the lateral ventricle. In the cerebrospinal fluid (CSF) examination, white blood cell count was 2,720 /mm3, glucose level was 4 mg/dL (simultaneous blood glucose level was 135 mg/dL), and CSF protein level was 2,025.4 mg/dL. On admission day 4, CSF culture showed Streptococcus pneumoniae. Despite continuous antibiotics treatment, she expired on admission day 7. In patients with pneumococcal ventriculitis, despite high mortality as in this case, early detection and treatment improve clinical outcome. Also aggressive treatment (intraventricular antibiotics injection, and pus drainage) should be considered.