Meningitis Guidelines

Updated: Oct 12, 2017
  • Author: Rodrigo Hasbun, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines

Infectious Diseases Society of America Guidelines on Healthcare-Associated Ventriculitis and Meningitis

Diagnosis

IDSA guidelines on the diagnosis of healthcare-associated ventriculitis and meningitis are as follows: [50]

  • New headache, fever, evidence of meningeal irritation, seizures, and/or worsening mental status suggest ventriculitis or meningitis in the setting of recent trauma or neurosurgery.
  • Fever, in the absence of another clear source of infection, suggests CNS infection in the setting of recent head trauma or neurosurgery.
  • New headache, nausea, lethargy, and/or change in mental status suggest CSF shunt infection.
  • Erythema and tenderness over the subcutaneous shunt tubing suggest CSF shunt infection.
  • Symptoms and signs of peritonitis or abdominal tenderness in patients with ventriculoperitoneal shunts, in the absence of another clear etiology, indicate CSF shunt infection.
  • Demonstration of bacteremia in a patient with a ventriculoatrial shunt, in the absence of another clear source of bacteremia, is evidence of CSF shunt infection.
  • Symptoms and signs of pleuritis in patients with ventriculopleural shunts, in the absence of another clear etiology, indicate CSF shunt infection.
  • Single or multiple positive CSF culture results in patients with CSF pleocytosis and/or hypoglycorrhachia, or an increasing cell count, and clinical symptoms suspicious for ventriculitis or meningitis, indicates CSF drain infection.
  • CSF cultures are the most important test to establish the diagnosis of healthcare-associated ventriculitis and meningitis.
  • If initial CSF culture results are negative in patients with CSF shunts or drains with suspected infection, cultures should be held for at least 10 days in an attempt to identify organisms such as P acnes.
  • Blood cultures are recommended in patients with suspected ventriculoatrial shunt infections.
  • CSF and blood cultures in selected patients should be obtained before the administration of antimicrobial therapy; a negative CSF culture result in the setting of previous antimicrobial therapy does not exclude healthcare-associated ventriculitis and meningitis.
  • CSF pleocytosis with a positive culture result and symptoms of infection indicate a diagnosis of healthcare-associated ventriculitis or meningitis.
  • CSF cultures that grow S aureus or aerobic gram-negative bacilli indicate infection.
  • CSF cultures that grow a fungal pathogen indicate infection.
  • Neuroimaging is recommended in patients with suspected healthcare-associated ventriculitis and meningitis.
  • MRI with gadolinium enhancement and diffusion-weighted imaging is recommended for detecting abnormalities in patients with healthcare-associated ventriculitis and meningitis.
  • In patients with infected ventriculoperitoneal shunts and abdominal symptoms (eg, pain or tenderness), ultrasonography or CT scanning of the abdomen is recommended to detect CSF loculations at the shunt terminus.

Treatment

IDSA guidelines on the treatment of healthcare-associated ventriculitis and meningitis are as follows: [50]

  • Vancomycin plus an anti-pseudomonal beta-lactam (eg, cefepime, ceftazidime, or meropenem) is recommended as empiric therapy for healthcare-associated ventriculitis and meningitis; the choice of empiric beta-lactam agent should be based on local in vitro susceptibility patterns.
  • In seriously ill adult patients with healthcare-associated ventriculitis and meningitis, the vancomycin trough concentration should be maintained at 15-20 μg/mL in those who receive intermittent bolus administration.
  • For patients with healthcare-associated ventriculitis and meningitis who have experienced anaphylaxis to beta-lactam antimicrobial agents and in whom meropenem is contraindicated, aztreonam or ciprofloxacin is recommended for gram-negative coverage.
  • For treatment of infection caused by methicillin-susceptible S aureus (MSSA), nafcillin or oxacillin is recommended. If the patient cannot receive beta-lactam agents, the patient can be desensitized or may receive vancomycin as an alternative agent.
  • For treatment of infection caused by methicillin-resistant S aureus (MRSA), vancomycin is recommended as first-line therapy, with consideration for an alternative antimicrobial agent if the vancomycin minimal inhibitory concentration (MIC) is ≥1 μg/mL.
  • Infections caused by S aureus or gram-negative bacilli with or without significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features should be treated for 10-14 days (strong, low); some experts suggest treatment of infection caused by gram-negative bacilli for 21 days.
  • For treatment of infection caused by coagulase-negative staphylococci, the recommended therapy should be similar to that for S aureus and based on in vitro susceptibility testing.
  • Rifampin is recommended as part of combination therapy for any patient with intracranial or spinal hardware such as a CSF shunt or drain.
  • For treatment of patients with healthcare-associated ventriculitis and meningitis caused by staphylococci in whom beta-lactam agents or vancomycin cannot be used, linezolid, daptomycin, or trimethoprim-sulfamethoxazole is recommended, with selection of a specific agent based on in vitro susceptibility testing.
  • For treatment of infection caused by P acnes, penicillin G is recommended.
  • Infections caused by a coagulase-negative Staphylococcus or P acnes with no or minimal CSF pleocytosis, normal CSF glucose, and few clinical symptoms or systemic features should be treated for 10 days.
  • Infections caused by a coagulase-negative Staphylococcus or P acnes with significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features should be treated for 10-14 days.
  • For treatment of infection caused by gram-negative bacilli susceptible to third-generation cephalosporins, ceftriaxone or cefotaxime is recommended.
  • For treatment of infection caused by Pseudomonas species, the recommended therapy is cefepime, ceftazidime, or meropenem; recommended alternative antimicrobial agents are aztreonam or a fluoroquinolone with in vitro activity.
  • For treatment of infection caused by Acinetobacter species, meropenem is recommended; for strains that demonstrate carbapenem resistance, colistimethate sodium or polymyxin B (either agent administered by the intravenous and intraventricular routes) is recommended.
  • Prolonged infusion of meropenem (each dose administered over 3 hours) may be successful in treating resistant gram-negative organisms.
  • For treatment of infection caused by Candida species, based on in vitro susceptibility testing, liposomal amphotericin B, often combined with 5-flucytosine, is recommended; once the patient shows clinical improvement, therapy can be changed to fluconazole if the isolated species is susceptible.
  • For treatment of infection caused by Aspergillus or Exserohilum species, voriconazole is recommended.
  • When antimicrobial therapy is administered via a ventricular drain, the drain should be clamped for 15-60 minutes to allow the agent to equilibrate throughout the CSF.
  • Dosages and intervals of intraventricular antimicrobial therapy should be adjusted based on CSF antimicrobial concentrations to 10-20 times the MIC of the causative microorganism, ventricular size, and daily output from the ventricular drain.
  • In patients with repeatedly positive CSF cultures on appropriate antimicrobial therapy, treatment should be continued for 10-14 days after the last positive culture.