Subarachnoid Hemorrhage and Ventriculitis

Clinical signs of ventriculitis are difficult to recognize in SAH patients who are sedated, who have recently undergone neurosurgery, or have a sterile inflammatory response in the CSF due to the SAH.  Clinical symptoms of SAH (headache, nuchal rigidity, AMS) closely resemble bacterial ventriculitis.

Suspect with:
  • new fever
    • Fever occurs in 40 % after SAH +/- infection
  • new nuchal rigidity

 

What to do?

Exclude other causes of infection

  1. physical examination
  2. blood / sputum / urinary cultures
  3. CXR

Exclude other causes of AMS (HCP and ischemia)

  • Neuroimaging with plain CT scan
Work-up:
  • Serum:  CRP WBC glucose
  • CSF analysis (cell count, GS / CS, glu / protein)
    • Interpretation of CSF WBC problematic; CSF RBC causes aseptic ventriculitis
    • CSF cell count  helpful but low sensitivity and specificity
      CSF RBC higher in CSF culture-negative bacterial ventriculitis
    • cell index for EVD-related ventriculitis with IVH (formula proposed, but not yet validated)
  • Blood cultures
  • CSF lactate, cytokine levels, and serum procalcitonin
    • Also disturbed after SAH
    • procalcitonin discriminates between SIRS and systemic infection but value for aseptic vs bacterial ventriculitis is limited
  • CSF PCR for bacterial pathogens – low sensitivity in EVD related bacterial ventriculitis and aseptic ventriculitis after surgery
Case definitions:
  1. Clincally suspected bacterial ventriculitis – empirical antibiotic treatment for bacterial ventriculitis, but negative CSF cultures
  2. Confirmed Bacterial ventriculitis – (+) CSF culture for bacteria; if staph epidermidis – needs 2 consecutive positive cultures to rule out contamination
Treatment:
  • No good discriminative tests, treatment initiated on first suspicion
  • Antibiotic regimen for bacterial ventriculitis
    •  ceftriaxone 2 g BID + vancomycin 2 g BID
    •  ceftazidime 2 g TID + vancomycin 2 g BID if external CSF catheter in place
  • Duration
    • culture negative – discontinue ABx (after 72h)
    • culture positive – 2 weeks

 

ORDERS:
  1. Physical Examination
  2. Assessment:
    • clinically suspected bacterial ventriculitis
    • confirmed bacterial ventriculitis
  3. Blood work:
    • CBC (WBC)
    • BMP (glucose)
    • Blood cultures x 2
    • CRP
    • Procalcitonin
  4. sputum cultures
  5. urinalysis with reflex to urine culture if (+)
  6. CXR
  7. Plain CT scan
  8. CSF studies
    • cell count
    • Gram stain and culture
    • CSF glucose
    • CSF protein
    • calculate cell index
    • CSF lactate
    • *CSF cytokine levels
    • *CSF PCR for bacterial pathogens
  9. Treatment x 2 weeks
    • ceftriaxone 2 g BID + vancomycin 2 g BID
    • ceftazidime 2 g TID + vancomycin 2 g BID if (+) EVD
    • discontinue within 72 hours if cultures are negative

 

Reference:

Hoogmoed, J. et al. “Clinical And Laboratory Characteristics For The Diagnosis Of Bacterial Ventriculitis After Aneurysmal Subarachnoid Hemorrhage”. Neurocritical Care (2016): 1-9.

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