Current Treatment Options in Neurology

, Volume 8, Issue 2, pp 135–144

Central nervous system infections in the neurointensive care unit

  • Fred Rincon
  • Neeraj Badjatia
Article

Opinion statement

Central nervous system (CNS) infections are frequently encountered at the primary care level, in emergency rooms, medical wards, and intensive care units. Advances in immunization techniques and aggressive prevention campaigns have had an impact on the worldwide incidence of community-acquired meningitis, limiting this disease to the adult population. In general, a high index of suspicion is required for the diagnosis, but special attention should be given to the immunocompromised host and post-neurosurgical patient in whom the clinical presentation may be nonspecific. Once the diagnosis is made, broadspectrum antimicrobials should be administered, followed by diagnostic testing, and targeted antibiotic therapy. Current guidelines for the treatment of meningitis are clinically effective but are not based on randomized, prospective, controlled trials. Despite current therapies, the morbidity of CNS infections is still devastating. Recent trials of the use of corticosteroids as coadjuvants of antibiotic therapy showed promising results and decrease in the morbidity associated with bacterial and tuberculous meningitis. Additional neuroprotective alternatives should be the focus of future research. Similarly, guidelines for the diagnosis and management of post-neurosurgical procedure meningitis and ventriculostomy-related infections are needed.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Spach DH, Jackson LA: Bacterial meningitis. Neurol Clin 1999, 17:711–735.PubMedCrossRefGoogle Scholar
  2. 2.
    Shadravan I, Fishbein J, Hebert LJ: Streptococcal meningitis with an unusual port of entry. Am J Dis Child 1976, 130:214–215.PubMedGoogle Scholar
  3. 3.
    Durand ML, Calderwood SB, Weber DJ, et al.: Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 1993, 328:21–28. A very large, well-characterized retrospective review of bacterial meningitis cases that provides a great deal of epidemiologic data and information regarding risk factors.PubMedCrossRefGoogle Scholar
  4. 4.
    Coyle PK: Overview of acute and chronic meningitis. Neurol Clin 1999, 17:691–710.PubMedCrossRefGoogle Scholar
  5. 5.
    Thwaites GE, Tran TH: Tuberculous meningitis: many questions, too few answers. Lancet Neurol 2005, 4:160–170.PubMedGoogle Scholar
  6. 6.
    Holloway RG, Kieburtz KD: Neurologic Manifestations of Human Immunodeficiency Virus Infection, edn 5. New York: Churchill-Livingstone; 2000.Google Scholar
  7. 7.
    Diamond RD: Cryptococcus neoformans. New York: Churchill-Livingstone; 2000.Google Scholar
  8. 8.
    van de Beek D, de Gans J, Spanjaard L, et al.: Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004, 351:1849–1859.PubMedCrossRefGoogle Scholar
  9. 9.
    Hussein AS, Shafran SD: Acute bacterial meningitis in adults. A 12-year review. Medicine (Baltimore) 2000, 79:360–368.CrossRefGoogle Scholar
  10. 10.
    Tunkel AR, Hartman BJ, Kaplan SL, et al.: Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004, 39:1267–1284. The latest consensus guideline of the Infectious Diseases Society of America.PubMedCrossRefGoogle Scholar
  11. 11.
    Horwitz SJ, Boxerbaum B, O’Bell J: Cerebral herniation in bacterial meningitis in childhood. Ann Neurol 1980, 7:524–528.PubMedCrossRefGoogle Scholar
  12. 12.
    Korein J, Cravioto H, Leicach M: Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension. Neurology 1959, 9:290–297.PubMedGoogle Scholar
  13. 13.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr: Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2002, 51:170–181; discussion 181–182. Large, retrospective study and literature analysis of the occurrence and outcomes of post-neurosurgical ventriculitis.PubMedCrossRefGoogle Scholar
  14. 14.
    Mayhall CG, Archer NH, Lamb VA, et al.: Ventriculostomy-related infections A prospective epidemiologic study.N Engl J Med 1984, 310:553–559.PubMedCrossRefGoogle Scholar
  15. 15.
    Sundbarg G, Nordstrom CH, Soderstrom S: Complications due to prolonged ventricular fluid pressure recording.Br J Neurosurg 1988, 2:485–495.PubMedGoogle Scholar
  16. 16.
    Hader WJ, Steinbok P: The value of routine cultures of the cerebrospinal fluid in patients with external ventricular drains.Neurosurgery 2000, 46:1149–1153; discussion 1153–1155.PubMedCrossRefGoogle Scholar
  17. 17.
    Rosner MJ, Becker DP: ICP monitoring: complications and associated factors.Clin Neurosurg 1976, 23:494–519.PubMedGoogle Scholar
  18. 18.
    Lyke KE, Obasanjo OO, Williams MA, et al.: Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients.Clin Infect Dis 2001, 33:2028–2033.PubMedCrossRefGoogle Scholar
  19. 19.
    Holloway KL, Barnes T, Choi S, et al.: Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients.J Neurosurg 1996, 85:419–424.PubMedCrossRefGoogle Scholar
  20. 20.
    Narayan RK, Kishore PR, Becker DP, et al.: Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury.J Neurosurg 1982, 56:650–659.PubMedGoogle Scholar
  21. 21.
    Kanter RK, Weiner LB, Patti AM, Robson LK: Infectious complications and duration of intracranial pressure monitoring.Crit Care Med 1985, 13:837–839.PubMedCrossRefGoogle Scholar
  22. 22.
    Winfield JA, Rosenthal P, Kanter RK, Casella G: Duration of intracranial pressure monitoring does not predict daily risk of infectious complications. Neurosurgery 1993, 33:424–430; discussion 430–431.PubMedCrossRefGoogle Scholar
  23. 23.
    Martinez E, Rello J, Coll P: Clinical diagnosis of ventriculostomy-related infections.Lancet 1994, 344:1015–1016.PubMedCrossRefGoogle Scholar
  24. 24.
    Smith RW, Alksne JF: Infections complicating the use of external ventriculostomy.J Neurosurg 1976, 44:567–570.PubMedGoogle Scholar
  25. 25.
    Stenager E, Gerner-Smidt P, Kock-Jensen C: Ventriculostomy-related infections--an epidemiological study. Acta Neurochir (Wien) 1986, 83:20–23.CrossRefGoogle Scholar
  26. 26.
    Wyler AR, Kelly WA: Use of antibiotics with external ventriculostomies. J Neurosurg 1972, 37:185–187.PubMedGoogle Scholar
  27. 27.
    Buckwold FJ, Hand R, Hansebout RR: Hospitalacquired bacterial meningitis in neurosurgical patients. J Neurosurg 1977, 46:494–500.PubMedGoogle Scholar
  28. 28.
    Poon WS, Ng S, Wai S: CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Acta Neurochir Suppl 1998, 71:146–148.PubMedGoogle Scholar
  29. 29.
    Luerssen TG, Chesnut RM, van Berkum C, et al.: Posttraumatic cerebrospinal fluid interactions in the Traumatic Coma Data Bank: the influence of the type and management of ICP monitors. In Intracranial Pressure VIII: Proceedings of the 8th International Symposium on Intracranial Pressure. Edited by Avezaat CJJ, van Eijndhoven JHM, Maas AIR, Tans JTJ. Berlin: Springer-Verlag; 1993:42–45.Google Scholar
  30. 30.
    Schultz M, Moore K, Foote AW: Bacterial ventriculitis and duration of ventriculostomy catheter insertion. J Neurosci Nurs 1993, 25:158–164.PubMedGoogle Scholar
  31. 31.
    Korinek AM, Reina M, Boch AL, et al.: Prevention of external ventricular drain--related ventriculitis. Acta Neurochir (Wien) 2005, 147:39–45; discussion 45–46.CrossRefGoogle Scholar
  32. 32.
    Clark WC, Muhlbauer MS, Lowrey R, et al.: Complications of intracranial pressure monitoring in trauma patients.Neurosurgery 1989, 25:20–24.PubMedCrossRefGoogle Scholar
  33. 33.
    Paramore CG, Turner DA: Relative risks of ventriculostomy infection and morbidity.Acta Neurochir (Wien) 1994, 127:79–84.CrossRefGoogle Scholar
  34. 34.
    Zabramski JM, Whiting D, Darouiche RO, et al.: Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial.J Neurosurg 2003, 98:725–730.PubMedCrossRefGoogle Scholar
  35. 35.
    Aucoin PJ, Kotilainen HR, Gantz NM, et al.: Intracranial pressure monitors. Epidemiologic study of risk factors and infections.Am J Med 1986, 80:369–376.PubMedCrossRefGoogle Scholar
  36. 36.
    Lundberg F, Wady L, Soderstrom S, et al.: External ventricular drainage catheters: effect of surface heparinization on bacterial colonization and infection.Acta Neurochir (Wien) 2000, 142:1377–1383.CrossRefGoogle Scholar
  37. 37.
    Kaufmann AM, Lye T, Redekop G, et al.: Infection rates in standard vs. hydrogel coated ventricular catheters. Can J Neurol Sci 2004, 31:506–510.PubMedGoogle Scholar
  38. 38.
    Alleyne CHJr, Hassan M, Zabramski JM: The efficacy and cost of prophylactic and perioprocedural antibiotics in patients with external ventricular drains.Neurosurgery 2000, 47:1124–1127; discussion 1127–1129.PubMedCrossRefGoogle Scholar
  39. 39.
    Hasbun R, Abrahams J, Jekel J, Quagliarello VJ: Computed tomography of the head before lumbar puncture in adults with suspected meningitis.N Engl J Med 2001, 345:1727–1733. Large, prospective study that followed 301 adults with suspected meningitis to determine whether clinical characteristics that were present could be used to identify patients who were unlikely to have abnormalities on CT.PubMedCrossRefGoogle Scholar
  40. 40.
    de Gans J, van de Beek D: Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002, 347:1549–1556. A prospective, randomized, double-blind, multicenter trial of adjuvant treatment with dexamethasone, compared with placebo, in adults with acute bacterial meningitis that found early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding.PubMedCrossRefGoogle Scholar
  41. 41.
    Treatment of tuberculosis. MMWR Recomm Rep 2003, 52:1–77.Google Scholar
  42. 42.
    Thwaites GE, Nguyen DB, Nguyen HD, et al.: Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004, 351:1741–1751.PubMedCrossRefGoogle Scholar
  43. 43.
    Saag MS, Powderly WG, Cloud GA, et al.: Comparison of amphotericin B with fluconazole in the treatment of acute AIDS-associated cryptococcal meningitis. The NIAID Mycoses Study Group and the AIDS Clinical Trials Group. N Engl J Med 1992, 326:83–89.PubMedCrossRefGoogle Scholar

Copyright information

© by Current Science Inc 2006

Authors and Affiliations

  • Fred Rincon
  • Neeraj Badjatia
    • 1
  1. 1.Division of Stroke and Critical Care Department of NeurologyColumbia University College of Physicians and Surgeons; Neurological InstituteNew YorkUSA

Personalised recommendations