Current Practices of Intraventricular Antibiotic Therapy in the Treatment of Meningitis and Ventriculitis: Results from a Multicenter Retrospective Cohort Study.

BACKGROUND: Central nervous system (CNS) infections are particularly prevalent in the adult neurocritical care patient population and are associated with significant morbidity and mortality. Factors relevant to the nature of CNS infections pose significant challenges to clinicians treating afflicted patients. Intraventricular (IVT) administration of antibiotics may offer several benefits over systemic therapy; however, the outcomes and current practices of such treatments are poorly described in the literature. OBJECTIVE: To describe current practices and outcomes of patients receiving intraventricular antibiotic treatment for CNS infections in neurological intensive care units of academic medical centers nationwide. METHODS: 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.

Medical marijuana in neurology.

Constituents of the Cannabis plant, cannabinoids, may be of therapeutic value in neurologic diseases. The most abundant cannabinoids are Δ(9)-tetrahydrocannabinol, which possesses psychoactive properties, and cannabidiol, which has no intrinsic psychoactive effects, but exhibits neuroprotective properties in preclinical studies. A small number of high-quality clinical trials support the safety and efficacy of cannabinoids for treatment of spasticity of multiple sclerosis, pain refractory to opioids, glaucoma, nausea and vomiting. Lower level clinical evidence indicates that cannabinoids may be useful for dystonia, tics, tremors, epilepsy, migraine and weight loss. Data are also limited in regards to adverse events and safety. Common nonspecific adverse events are similar to those of other CNS 'depressants' and include weakness, mood changes and dizziness. Cannabinoids can have cardiovascular adverse events and, when smoked chronically, may affect pulmonary function. Fatalities are rare even with recreational use. There is a concern about psychological dependence, but physical dependence is less well documented. Cannabis preparations may presently offer an option for compassionate use in severe neurologic diseases, but at this point, only when standard-of-care therapy is ineffective. As more high-quality clinical data are gathered, the therapeutic application of cannabinoids will likely expand.

Clobazam for treatment of epilepsy.

INTRODUCTION: The landscape of antiepileptic drugs is constantly evolving with new compounds being released onto the market on a regular basis. Most new agents are, at least initially, approved for use as adjunctive treatment of localization-related (focal) epilepsy, and only rarely are new medications released for other types of epilepsy. Though it has been in use in other countries, clobazam is now approved for use in the USA, and specifically in the treatment of Lennox-Gastaut syndrome, a type of (symptomatic or cryptogenic) generalized epilepsy. AREAS COVERED: This paper discusses the pharmacology of clobazam as well as the definition and nosologic boundaries of Lennox-Gastaut Syndrome. General (adult) neurologists are under the erroneous impression that Lennox-Gastaut syndrome is limited to childhood, and this common misconception indicates a lack of understanding of the group of generalized epilepsies. With this paper, readers will gain a better understanding of the limits of Lennox-Gastaut syndrome and how it evolves with age and what clobazam can contribute to its treatment. EXPERT OPINION: Clobazam offers a new treatment option for patients with refractory epilepsy. It has been found to be a safe, well-tolerated adjunctive antiepileptic medication that has had long-standing international experience in thousands of patients. It is unlikely that clobazam will change treatment strategies radically; nonetheless additional options are always welcome as individual patients can respond to different regimens. Physicians should be comfortable prescribing clobazam because it is a benzodiazepine and has been used extensively outside of the USA.