What are the IDSA guidelines on the treatment of healthcare-associated ventriculitis and meningitis?

Updated: Jul 16, 2019
  • Author: Rodrigo Hasbun, MD, MPH; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

IDSA guidelines on the treatment of healthcare-associated ventriculitis and meningitis are as follows: [52]

  • 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.

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