Healthcare-Acquired Meningitis and Ventriculitis

  • Tricia Bravo
  • Adarsh BhimrajEmail author


Healthcare-associated meningitis and cerebral ventriculitis are infections following craniotomies, spine surgeries, CSF shunt, CSF drain surgeries, and otorhinological surgeries. Gram-positive cocci like Staphylococcus epidermidis and S. aureus are the most common pathogens, followed by gram-negative rods and anaerobes like C. acnes (formerly P. acnes). Other noninfectious neurologic conditions and neurosurgeries can cause similar clinical and CSF findings making the diagnosis difficult. The management of these infections often requires surgical interventions and may need intraventricular or intrathecal administration of antimicrobials, when they don’t respond to IV antimicrobials alone. Periprocedural antimicrobials, antimicrobial-impregnated CSF catheters, and infection prevention protocols during insertion and maintenance of CSF shunts and drains have been shown to reduce infection rates.


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


  1. 1.
    Bhimraj A, Drake J, Tunkel A. Cerebrospinal fluid shunt and drain infections. In: Mandell G, Bennett J, Dolin R, editors. Principles and practice of infectious diseases. 8th ed. Philadelphia: Churchill Livingstone; 2014. p. 1186–93.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.CrossRefPubMedGoogle Scholar
  3. 3.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2008;62(Suppl 2):688–700.PubMedGoogle Scholar
  4. 4.
    Ramanan M, Lipman J, Shorr A, Shankar A. A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis. 2015;15:3. Scholar
  5. 5.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Braxton EE Jr, Ehrlich GD, Hall-Stoodley L, Stoodley P, Veeh R, Fux C, et al. Role of biofilms in neurosurgical device-related infections. Neurosurg Rev. 2005;28(4):249–55.CrossRefPubMedGoogle Scholar
  8. 8.
    Wang KW, Chang WN, Shih TY, Huang CR, Tsai NW, Chang CS, et al. Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis. 2004;57(2):44–8.PubMedGoogle Scholar
  9. 9.
    Sells CJ, Shurtleff DB, Loeser JD. Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics. 1977;59(4):614–8.PubMedGoogle Scholar
  10. 10.
    Brook I. Meningitis and shunt infection caused by anaerobic bacteria in children. Pediatr Neurol. 2002;26(2):99–105.CrossRefPubMedGoogle Scholar
  11. 11.
    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.CrossRefPubMedGoogle Scholar
  12. 12.
    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.CrossRefPubMedGoogle Scholar
  13. 13.
    O’Brien D, Stevens NT, Lim CH, O’Brien DF, Smyth E, Fitzpatrick F, et al. Candida infection of the central nervous system following neurosurgery: a 12-year review. Acta Neurochir. 2011;153(6):1347–50.CrossRefPubMedGoogle Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    Moores LE, Ellenbogen RG. Cerebrospinal fluid shunt infections. In: Hall WA, McCutcheon IE, AANS Publications Committee, editors. Infections in neurosurgery. Park Ridge: American Association of Neurological Surgeons; 2000. p. 53.Google Scholar
  16. 16.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Berger C, Schwarz S, Schaebitz WR, Aschoff A, Schwab S. Serum procalcitonin in cerebral ventriculitis. Crit Care Med. 2002;30(8):1778–81.CrossRefPubMedGoogle Scholar
  18. 18.
    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.CrossRefPubMedGoogle Scholar
  19. 19.
    Schuhmann MU, Ostrowski KR, Draper EJ, Chu JW, Ham SD, Sood S, et al. The value of C-reactive protein in the management of shunt infections. J Neurosurg. 2005;103(3 Suppl):223–30.PubMedGoogle Scholar
  20. 20.
    Lewis A, Wahlster S, Karinja S, Czeisler BM, Kimberly WT, Lord AS. Ventriculostomy-related infections: the performance of different definitions for diagnosing infection. Br J Neurosurg. 2016;30:49–56.CrossRefPubMedGoogle Scholar
  21. 21.
    Schade RP, Schinkel J, Roelandse FW, Geskus RB, Visser LG, van Dijk JM, 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.CrossRefPubMedGoogle Scholar
  22. 22.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    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. 2004;146(5):477–81.CrossRefPubMedGoogle Scholar
  24. 24.
    Grille P, Verga F, Biestro A. Diagnosis of ventriculostomy-related infection: is cerebrospinal fluid lactate measurement a useful tool. J Clin Neurosci. 2017;45:243–7.CrossRefPubMedGoogle Scholar
  25. 25.
    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
  26. 26.
    Forgacs P, Geyer CA, Freidberg SR. Characterization of chemical meningitis after neurological surgery. Clin Infect Dis. 2001;32(2):179–85.CrossRefPubMedGoogle Scholar
  27. 27.
    Xiao X, Zhang Y, Kang P, Ji N. The diagnostic value of cerebrospinal fluid lactate for post-neurosurgical bacterial meningitis: a meta-analysis. BMC Infect Dis. 2016;16:483.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Li Y, Zhang G, Ma R, Du Y, Zhang L, Li F, Fang F, Lv H, Wang Q, Zhang Y, Kang X. The diagnostic value of cerebrospinal fluids procalcitonin and lactate for the differential diagnosis of post-neurosurgical bacterial meningitis and aseptic meningitis. Clin Biochem. 2015;48(1–2):50–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Desai A, Lollis SS, Missios S, Radwan T, Zuaro DE, Schwarzman JD, et al. How long should cerebrospinal fluid cultures be held to detect shunt infections? Clinical article. J Neurosurg Pediatr. 2009;4(2):184–9.CrossRefPubMedGoogle Scholar
  30. 30.
    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.CrossRefPubMedGoogle Scholar
  31. 31.
    Spiegelman L, Asija R, Da Silva SL, Krieger MD, McComb JG. What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous tapping? J Neurosurg Pediatr. 2014;14(4):336–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Banks JT, Bharara S, Tubbs RS, Wolff CL, Gillespie GY, Markert JM, 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.CrossRefPubMedGoogle Scholar
  33. 33.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2002;51(1):170–81. discussion 181–82.CrossRefPubMedGoogle Scholar
  34. 34.
    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.CrossRefPubMedGoogle Scholar
  35. 35.
    Lodise TP Jr, 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.CrossRefPubMedGoogle Scholar
  36. 36.
    Nau R, Prange HW, Kinzig M, Frank A, Dressel A, Scholz P, et al. Cerebrospinal fluid ceftazidime kinetics in patients with external ventriculostomies. Antimicrob Agents Chemother. 1996;40(3):763–6.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Ricard JD, Wolff M, Lacherade JC, Mourvillier B, Hidri N, Barnaud G, 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.CrossRefPubMedGoogle Scholar
  38. 38.
    Wang JH, Lin PC, Chou CH, Ho CM, Lin KH, Tsai CT, et al. Intraventricular antimicrobial therapy in post neurosurgical Gram-negative bacillary meningitis or ventriculitis: a hospital-based retrospective study. J Microbiol Immunol Infect. 2014;47(3):204–10. Scholar
  39. 39.
    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.CrossRefPubMedGoogle Scholar
  40. 40.
    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. Scholar
  41. 41.
    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.CrossRefPubMedGoogle Scholar
  42. 42.
    Imberti R, Cusato M, Accetta G, Marinò V, Procaccio F, Del Gaudio A, et al. Pharmacokinetics of colistin in cerebrospinal fluid after intraventricular administration of colistin methanesulfonate. Antimicrob Agents Chemother. 2012;56(8):4416–21.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Ziai WC, Lewin JJ 3rd. Improving the role of intraventricular antimicrobial agents in the management of meningitis. Curr Opin Neurol. 2009;22(3):277–82.CrossRefPubMedGoogle Scholar
  44. 44.
    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.CrossRefPubMedGoogle Scholar
  45. 45.
    Shah SS, Ohlsson A, Shah VS. Intraventricular antibiotics for bacterial meningitis in neonates. Cochrane Database Syst Rev. 2012;7:CD004496.Google Scholar
  46. 46.
    Cook AM, Mieure KD, Owen RD, Pesaturo AB, Hatton J. Intracerebroventricular administration of drugs. Pharmacotherapy. 2009;29(7):832–45.CrossRefPubMedGoogle Scholar
  47. 47.
    Brown EM, Edwards RJ, Pople IK. Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery. 2006;58(4):657–65. discussion 657–65.CrossRefPubMedGoogle Scholar
  48. 48.
    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
  49. 49.
    Ellner PD, Neu HC. The inhibitory quotient. A method for interpreting minimum inhibitory concentration data. JAMA. 1981;246(14):1575–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39(9):1267–84.CrossRefPubMedGoogle Scholar
  51. 51.
    Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J. 2002;21(7):632–6.CrossRefPubMedGoogle Scholar
  52. 52.
    Yogev R. Cerebrospinal fluid shunt infections: a personal view. Pediatr Infect Dis. 1985;4(2):113–8.CrossRefPubMedGoogle Scholar
  53. 53.
    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.CrossRefPubMedGoogle Scholar
  54. 54.
    Barker FG 2nd. Efficacy of prophylactic antibiotics against meningitis after craniotomy: a meta-analysis. Neurosurgery. 2007;60(5):887–94. discussion 887–94.CrossRefPubMedGoogle Scholar
  55. 55.
    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.CrossRefPubMedGoogle Scholar
  56. 56.
    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.CrossRefPubMedGoogle Scholar
  57. 57.
    Alleyne CH Jr, 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.CrossRefPubMedGoogle Scholar
  58. 58.
    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
  59. 59.
    Sonabend AM, Korenfeld Y, Crisman C, Badjatia N, Mayer SA, Connolly ES Jr. Prevention of ventriculostomy-related infections with prophylactic antibiotics and antibiotic-coated external ventricular drains: a systematic review. Neurosurgery. 2011;68(4):996–1005.CrossRefPubMedGoogle Scholar
  60. 60.
    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.CrossRefPubMedGoogle Scholar
  61. 61.
    Kestle JRW, Riva-Cambrin J, Wellons JC 3rd, et al. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr. 2011;8:22–9.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Kestle JR, Holubkov R, Douglas Cochrane D. A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr. 2016;17:391–6.CrossRefPubMedGoogle Scholar
  63. 63.
    Flint AC, Rao VA, Renda NC, Faigeles BS, Lasman TE, Sheridan W. A simple protocol to prevent external ventricular drain infections. Neurosurgery. 2013;72:993–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Flint AC, Toossi S, Chan SL, Rao VA, Sheridan W. A simple infection control protocol durably reduces external ventricular drain infections to near-zero levels. World Neurosurg. 2017;99:518 523.CrossRefPubMedGoogle Scholar
  65. 65.
    Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis. 2017;64:e34–65.CrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

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

Personalised recommendations