Lavado endoscópico con colocación de catéter trans acueducto de Silvio en paciente lactante con ventriculitis de difícil manejo / Endoscopic lavage with placement of a trans-aqueduct of Silvio catheter in a nursing patient with difficult-to-manage ventriculitis

Introducción: La ventriculitis representa una emergencia infectológica, generalmente asociada a un procedimiento neuroquirúrgico. La incidencia es desconocida debido a la variación de los criterios diagnóstico. Descripción del caso: Presentamos una paciente de sexo femenino de 6 meses de edad con antecedente de hidrocefalia post hemorrágica, con diagnóstico de ventriculitis por Enterobacter complex asociada a sistema de derivación ventrículo peritoneal (DVP) de difícil manejo. La misma realizó tratamiento combinado de antibiótico con Meropenem y Colistin endovenoso e intraventricular asociado a tratamiento endoscópico que consistió en lavados, aspiración del contenido purulento intraventricular, tercer ventriculostomía endoscópica (TVE), coagulación bilateral del plexo coroideo y acueductoplastia con colocación de catéter de derivación ventricular externa (DVE) entre el tercer y el cuarto ventrículo con el objetivo de mantener la permeabilidad de la misma y de esta manera asegurar la llegada de antibiótico intraventricular al cuarto ventrículo. Discusión: La ventriculitis se asocia a múltiples complicaciones y una elevada tasa de morbi-mortalidad. El tratamiento de las ventriculitis de difícil manejo, es aún controvertido, actualmente existe bibliografía que reporta buenos resultados del tratamiento con lavado endoscópicos asociado al tratamiento combinado endovenoso e intraventricular para lograr mayores concentraciones de antibiótico intraventricular. Conclusión: Consideramos que el tratamiento combinado es una herramienta frente a las ventriculitis por patógenos resistentes a los tratamientos convencionales. En los casos con obstrucción del acueducto de Silvio recomendamos realizar acueductoplastia y colocación de catéter multifenestrado; para mantener la permeabilidad y la llegada de antibiótico al cuarto ventrículo.

Introduction: Ventriculitis represents an infectious emergency which is normally associated with neurosurgical procedures. The incidence is unknown due to the variation of the diagnostic criteria. Case description: We present a 6-month-old female patient with a history of post-hemorrhagic hydrocephalus. The patient was diagnosed with Enterobacter complex ventriculitis difficult to manage associated with peritoneal ventricular shunt (VP). The patient received combined antibiotic treatment with Meropenem intravenous and intravenous-intraventricular Colistin associated with endoscopic treatment. This endoscopic treatment consisted of washes, aspiration of the intraventricular purulent content, third endoscopic ventriculostomy (ETV), bilateral coagulation of the choroid plexus and aqueductoplasty with external ventricular drain catheter (EDV). This EDV was placed between the third and fourth ventricle in order to maintain its permeability so as to ensure the arrival of intraventricular antibiotics to the fourth ventricle. Discussion: Ventriculitis is associated with multiple complications and a high morbidity and mortality rate. The treatment of ventriculitis that is difficult to manage is still controversial. Currently several authors show good results of endoscopic lavage treatment associated with combined intravenous/intraventricular antibiotic treatment. This leads to greater intraventricular antibiotic concentrations. Conclusion: We consider that combined treatment has been successful for ventriculitis difficult to manage. In those cases, with obstruction of the Silvio aqueduct, it is recommended to perform aqueductoplasty and placement of a multi-fenestrated catheter; to maintain patency and the arrival of antibiotics in the fourth ventricle.

Uso compasional de tigeciclina intraventricular en pacientes con ventriculitis causada por Enterococcus faecium. Reporte de seis casos pediátricos / Compassional use of Intraventricular Tigecycline in ventriculitis caused by Enterococcus faecium. Six pediatric cases

Introducción: La Tigeciclina es un fármaco de uso restringido en pediatría. El uso de este antibiótico por vía intraventricular es una decisión de uso compasivo en casos de bacterias altamente resistentes, y para los casos en que no exista otra alternativa. Caso clínico: Se presenta seis casos de pacientes con diagnóstico de ventriculitis a Enterococcus faecium que recibieron tigeciclina intraventricular con evolución bacteriológica exitosa. Se discute las dosis utilizadas por vía endovenosa e intraventricular. Conclusiones: el uso de este antibiótico por vía intraventricular puede ser una alternativa exitosa en casos de gérmenes altamente resistentes y cuando no exista otra alternativa terapéutica.

Introduction: Tigecycline is a drug of restricted use in pediatrics. The use of this antibiotic intraventricularly is a decision of compassive use in cases of highly resistant bacteria, and in cases where there is no other alternative. Clinical case: We present six cases of patients with a diagnosis of ventriculitis caused by Enterococcus faecium, who received intraventricular tigecycline with successful microbiological evolution. The doses used intravenously and intraventricularly are discussed. Conclusions: the use of this antibiotic intraventricularly can be a successful alternative in cases of highly resistant germs, when there are not alternative options. Key words: ventriculitis, Enterococcus faecium, tigecycline, intraventricula

Infecciones postneuroquiróºrgicas: Puesta al día y recomendaciones intersociedades / Post-neurosurgical infections. Update and intersociety recommendations

Las infecciones asociadas a procedimientos neuroquiró;ºrgicos son complicaciones graves que contribuyen a la morbimortalidad de los pacientes neurocríticos, así como tambín a la prolongació;n de la estancia en la UTI y/o en el hospital. El diagnó;stico es complejo ya que no se dispone de gold standard y se apoya en la sospecha clínica, las alteraciones físico-químicas del líquido cefalorraquídeo y el aislamiento microbiano. El tratamiento debe ser precoz y guiado por la epidemiología local. La duració;n dependerá del microorganismo causal, su sensibilidad y la disponibilidad de tratamientos antibió;ticos efectivos en el sitio de la infecció;n. La implementació;n de medidas de prevenció;n con evidencia demostrada minimiza el riesgo de infecció;n. Esta puesta al día intersociedades SADI-SATI presenta datos epidemioló;gicos (internacionales y locales), mó;©todos diagnó;sticos, tratamiento, y pautas de prevenció;n, considerando las publicaciones más relevantes de los ó;ºltimos aó;±os sobre el tema.

Infections associated with neurosurgical procedures are serious complications that contribute to the morbidity and mortality of neurocritical patients, as well as to the prolongation of the stay in the ICU and the hospital. The diagnosis is complex since there is no gold standard, so it is based on clinical suspicion, CSF physical-chemical examination, and microbial isolation. Treatment should be initiated early, guided by local epidemiology. The duration will depend on the causative microorganism, its sensitivity and the availability of antibiotic treatments that are effective at the site of infection. The implementation of preventive measures with proven efficacy minimizes the risk of infection. This SADI-SATI intersociety update reviews relevant data recently published on this area at the national at international level regarding epidemiology, diagnostic methodologies, therapeutic approaches, and prevention guidelines.

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.

Ventriculitis post-quirúrgica por Pseudomonas aeruginosa extensamente resistente tratada con colistina intratecal. Comunicación de un caso pediátrico y revisión de la literatura científica / Post-surgical ventriculitis due to extensively resistant Pseudomonas aeruginosa treated with intrathecal colistin. Pediatric case report and literature review

Resumen El uso de colistina por vía intratecal se ha consolidado como una opción terapéutica para el manejo de infecciones del sistema nervioso central causadas por bacilos gramnegativos multi-resistentes. La evidencia del éxito terapéutico y del perfil de seguridad es creciente, particularmente en infecciones por Acinetobacter baumanii multi-resistente en adultos. La evidencia en niños es escasa. Se presenta el caso clínico de una niña de 11 años de edad, con una ventriculitis post-quirúrgica por Pseudomonas aeruginosa extensamente resistente tratada con colistina intravenosa e intratecal. Se revisa su uso en niños con meningitis nosocomial causada por bacilos gramnegativos multi-resistentes.

Use of Intrathecal colistin has increased in recent years and has become an alternative for the management of infections of the central nervous system caused by multidrug resistant (MDR) bacteria. Evidence of therapeutic success and safety profile is increasing, particularly in MDR Acinetobacter baumanii infections in adults. Conversely, evidence in children is limited. We present a case of an 11-year-old female with postsurgical meningitis caused by an extensively resistant Pseudomonas aeruginosa strain and treated with venous and intrathecal colistin. The evidence of its use in children with nosocomial meningitis by MDR Gram negative bacteria is reviewed.

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.

Ventriculitis e hidrocefalia secundaria a criptocococis meníngea en un paciente no-VIH: reporte de un caso en el Hospital de San José en 2014 / Ventriculitis and hydrocephalia secondary to meningeal cryptococcosis in a non-HIV patient: a case report in the Hospital de San Jose in 2014

La criptocococis meníngea es la infección fúngica más frecuente del sistema nervioso central; generalmente se presenta en pacientes VIH seropositivos, aunque existe una proporción considerable de paciente VIH seronegativos, siendo en estos casos su presentación más agresiva. Esta infección tiene manifestaciones neurológicas variables que son secundarias al aumento de la presión intracraneal. La ventriculitis con hidrocefalia secundaria es una de las complicaciones de mayor morbi-mortalidad especialmente en pacientes VIH seronegativos. Presentamos un reporte de caso de criptocococis meníngea género Neoformans subtipo Grubbi con ventriculitis e hidrocefalia secundaria en paciente VIH seronegativo confirmado por histopatología.

Meningeal criptocococis is the most common fungal infection of the central nervous system, occuring in HIV seropositive patients, although there is a significant proportion of HIV seronegative patients, in whom the presentation is more aggresive. This infection has variable clinical manifestations secondary to increased intracranial pressure. Ventriculitis with hydrocephalus is one of the complications with the poorest outcome and mortality especially in HIV seronegative patients. We present a case report of meningeal criptocococis Neoformans subtype Grubbi with ventriculitis and secondary hydrocephalus in HIV seronegative patient confirmed by histopathology.

Incidencia de ventriculitis relacionada a sistemas de derivación externa en el servicio de neurocirugía del Hospital General del Instituto Salvadoreño del Seguro Social. Enero 2013 a diciembre 2014 / Incidence of ventriculitis related to external shunt systems in the neurosurgery service of the General Hospital of the "Instituto Salvadoreño del Seguro Social". January 2013 to December 2014

El presente trabajo de investigación tiene como finalidad evaluar la incidencia de ventriculitis así como los agentes patógenos asociados en aquellos pacientes con ventriculostomía ingresados en el servicio de neurocirugía del Instituto Salvadoreño del Seguro Social (ISSS) durante el periodo de enero de 2013 a diciembre 2014. La metodología será la recopilación de datos a través de la revisión de expedientes clínicos de pacientes ingresados en el servicio de neurocirugía que hayan sido ingresados durante el periodo de enero 2013 a diciembre 2014; y que además se les haya realizado ventriculostomía dentro de las instalaciones de la institución. Con los datos obtenidos se podrá establecer la incidencia de paciente con dicha infección, así como la flora bacteriana asociada. Será de suma importancia el resultado de datos para poder contribuir al registro estadístico de la institución, ya que la previa instrumentalización y la aplicación de sistemas derivativos ventriculares expone al paciente a correr riesgos inherentes al procedimiento quirúrgico, a saber: daño hipotalámico, sangrado, infecciones, déficit neurológico, convulsiones, obstrucción del sistema y hasta la muerte. Al finalizar la investigación se podrá contribuir con la incidencia y conocer la flora bacteriana más común asociada, para ulteriormente poder recomendar que medidas preventivas para evitar dichas infecciones deben ser fortalecidas y la actualización en el cuidado del paciente con derivaciones ventriculares externas

Ventriculostomy Infections at the Paediatric Neurosurgical Unit at Dr George Mukhari Academic Hospital

Background. External ventricular drains (EVDs) are essential to the clinical management and care of patients with neurosurgical complications; but EVD use is routinely associated with concomitant infection; sometimes resulting in mortality. Objective. To undertake an epidemiological study of ventriculostomy-related infections among paediatric neurosurgical patients at the Dr George Mukhari Academic Hospital; Pretoria; South Africa. Methods. Retrospective analysis was conducted on the clinical records of 92 children admitted to the neurosurgical unit at the hospital between 2010 and 2013. Records were included in the study only if they were complete; legible and accurate. Data were collected on the following variables: age; gender; frequency of catheter change; cerebrospinal fluid (CSF) sampling; use of prophylaxis; microbiology; Glasgow Coma Scale; glucose; chlorine; and other clinical; chemical and laboratory parameters routinely observed as part of patients' work-ups. Results. Two or more EVDs were placed on 45.7 (40) children; with a maximum of seven EVDs per child. Ventriculitis incidence was 28.3 (26 of 92). There was a significant association between the number of EVDs inserted and the incidence of ventriculitis (p=0.010). More frequent CSF sampling also increased ventricular-related infections (p=0.000); as did prolonged EVD retention (p=0.001). Using prophylactic antibiotics or impregnated catheters did not reduce ventriculitis incidence significantly. Conclusion. Evidence supports adherence to strict sterilisation protocols and techniques when inserting EVDs. Catheters should not be retained for extended periods; and CSF sampling can be limited to once in 3 days. Routine use of antibiotic-impregnated EVDs and antistaphylococcal prophylaxis is still recommended

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.

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.

External ventricular drain infections: successful implementation of strategies to reduce infection rate

<p><b>INTRODUCTION</b>External ventricular drain (EVD) infections can cause serious complications. We performed an audit of EVD infections within our neurosurgical unit. Through this study, we aimed to reduce the incidence of external ventricular drain-related infection, including ventriculities in neurosurgical patients.</p><p><b>METHODS</b>We conducted an audit of the EVD infections in our institution observed over a one-and-a-half year period. This was conducted in three phases. A baseline EVD infection rate was determined for Phase I, from January to June 2007. We introduced the following measures to reduce EVD infection rate in Phase II, from July to December 2007: (1) For Neurosurgery doctors: performing proper surgical techniques to minimise intra-operative infections; educating junior doctors on proper CSF sampling from the EVD; and minimising the number of days the EVD is maintained in situ; (2) For Neurosurgery nurse clinicians: developing Standard Operating Procedures on nursing management of EVDs; conducting EVD care workshops for nurses working in neurosurgical wards; and competency skill checks on the management of EVDs for nurses working in the neurosurgical wards. Silver-coated EVDs were introduced in Phase III of the study from January to June 2008.</p><p><b>RESULTS</b>The EVD infection rate decreased from a baseline of 6.1% to 3.8% in Phase II; a further reduction from 3.8% to 0% was achieved during Phase III.</p><p><b>CONCLUSION</b>Good teamwork among doctors and nurses is essential for reducing EVD infection rate. We managed to reduce EVD infections substantially and would continue to strive to remain infection-free in the future.</p>

Neuroendoscopic surgery for unilateral hydrocephalus due to inflammatory obstruction of the Monro foramen / Cirurgia neuroendoscópica para tratamento da hidrocefalia unilateral secundária à obstrução inflamatória do forame de Monro

OBJECTIVE: Unilateral hydrocephalus (UH) is characterized by enlargement of just one lateral ventricle. In this paper, the authors will demonstrate their experiences in the neuroendoscopic management of this uncommon type of hydrocephalus. METHOD: The authors retrospectively reviewed a serie of almost 800 neuroendoscopic procedures performed from September 1995 to July 2010 and selected seven adult patients with UH. Clinical and radiological charts were reviewed and analyzed. RESULTS: Six patients had intraventricular neurocysticercosis and one patient had congenital stenosis of the foramen of Monro. Headaches were the most common symptom. A septostomy restored cerebrospinal fluid circulation. During follow-up period (65.5 months, range 3-109) no patient has presented clinical recurrence as well as no severe complications have been observed. CONCLUSION: UH is a rare condition. A successful treatment can be accomplished through a neuroendoscopic approach avoiding the use of ventricular shunts.

OBJETIVO: Hidrocefalia unilateral (HU) é caracterizada pelo alargamento de apenas um dos ventrículos laterais. Neste estudo, os autores demonstraram sua experiência no manejo deste tipo incomum de hidrocefalia. MÉTODO: Foram revisados, de uma série de quase 800 cirurgias neuroendoscópicas realizadas entre Setembro de 1995 e Julho de 2010, sete pacientes adultos com diagnóstico de HU. Dados clínicos e radiológicos foram analisados. RESULTADOS: Seis pacientes tinham neurocisticercose intraventricular e um apresentava uma estenose congênita do forame de Monro. Cefaléia foi o sintoma clínico mais comum. Uma septostomia restabeleceu o fluxo liquórico. Durante o seguimento (65,5 meses, de 3-109), nenhum paciente apresentou recorrência clínica assim como nenhuma complicação grave foi observada. CONCLUSÃO: HU é uma condição rara. O tratamento satisfatório pode ser alcançado por meio de uma abordagem neuroendoscópica evitando, desta maneira, o uso de sistemas de derivação ventricular.

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.

Intraventricular Pefloxacine Therapy for a Cerebral Ventriculitis by Enterobacter Aerogenes: Case Report

No abstract available.