Table 1.
Adherence to selected 2017 IDSA guidelines for the diagnosis and treatment of CSF shunt infection (n=145)
| Management of Staphylococcus aureus | n=47 |
|---|---|
| 41. For treatment of infection caused by methicillin-susceptible S. aureus, nafcillin or oxacillin is recommended (strong, moderate)…. | 25/33 (76%) |
| 42. For treatment of infection caused by methicillin-resistant S. aureus, vancomycin is recommended as first-line therapy (strong, moderate)….. |
13/14 (93%) |
| 44. If the staphylococcal isolate is susceptible to rifampin, this agent may be considered in combination with other antimicrobial agents for staphylococcal ventriculitis and meningitis (weak, low); rifampin is recommended as part of combination therapy for any patient with intracranial or spinal hardware such as a CSF shunt or drain (strong, low). | 13/27 (48%) |
| 60. Infections caused by S. aureus … with or without significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features should be treated for 10–14 days (strong, low)… | 12/47 (26%) |
| 61. In patients with repeatedly positive CSF cultures on appropriate antimicrobial therapy, treatment should be continued for 10–14 after the last positive culture (strong, low). | 14/32 (44%) |
| 62. Complete removal of an infected CSF shunt and replacement with an external ventricular drain combined with intravenous antimicrobial therapy is recommended in patients with infected CSF shunts (strong, moderate). | 44/47 (94%) |
| 72. In patients with infection caused by S. aureus …, a new shunt should be reimplanted 10 days after CSF cultures are negative (strong, low). | 9/47 (19%) |
| Met all relevant criteria | 2/47 (4%) |
| Management of coagulase negative Staphylococci | n=52 |
|---|---|
| 43. 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 (strong, moderate).*
Methicillin-susceptible: nafcillin or oxacillin is recommended Methicillin-resistant: vancomycin is recommended as first-line therapy |
1/14 (7%) 35/36 (97%) |
| 44. If the staphylococcal isolate is susceptible to rifampin, this agent may be considered in combination with other antimicrobial agents for staphylococcal ventriculitis and meningitis (weak, low); rifampin is recommended as part of combination therapy for any patient with intracranial or spinal hardware such as a CSF shunt or drain (strong, low). | 11/31 (35%) |
| 58. Infections caused by a coagulase-negative staphylococcus … with no or minimal CSF pleocytosis, normal CSF glucose, and few clinical symptoms or systemic features should be treated (with nafcillin) for 10 days (strong, low). † | 4/5 (60%) |
| 59. Infections caused by a coagulase-negative staphylococcus … with significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features should be treated for 10–14 days (with nafcillin) (strong, low). † | 17/44 (39%) |
| 62. Complete removal of an infected CSF shunt and replacement with an external ventricular drain combined with intravenous antimicrobial therapy is recommended in patients with infected CSF shunts (strong, moderate). | 41/52 (79%) |
| 70. In patients with infection caused by coagulase-negative staphylococci …, with no associated CSF abnormalities and with negative CSF cultures for 48 hours after externalization, a new shunt should be reimplanted as soon as the third day after removal (strong, low). † | 0/2 (0%) |
| 71. In patients with infection caused by a coagulase-negative staphylococcus …, with associated CSF abnormalities but negative repeat CSF cultures, a new shunt should be reimplanted after 7 days of antimicrobial therapy (strong, low); †
if repeat cultures are positive, antimicrobial treatment is recommended until CSF cultures remain negative for 7–10 consecutive days before a new shunt is placed (strong, low). |
2/23 (9%) 13/24 (54%) |
| Met all relevant criteria | 1/52 (2%) |
| Management of Propionibacterium acnes | n=9 | |
|---|---|---|
| 46. For treatment of infection caused by Propionibacterium acnes, penicillin G is recommended (strong, moderate). | 0 (0%) | |
| 58. Infections caused by … P. acnes with no or minimal CSF pleocytosis, normal CSF glucose, and few clinical symptoms or systemic features should be treated for 10 days (with penicillin) (strong, low).* | 0/5 (0%) | |
| 59. Infections caused by … P. acnes with significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features should be treated for 10–14 days (with penicillin) (strong, low).* | 0/3 (0%) | |
| 62. Complete removal of an infected CSF shunt and replacement with an external ventricular drain combined with intravenous antimicrobial therapy is recommended in patients with infected CSF shunts (strong, moderate). | 6/9 (67%) | |
| 70. In patients with infection caused by … P. acnes, with no associated CSF abnormalities and with negative CSF cultures for 48 hours after externalization, a new shunt should be reimplanted as soon as the third day after removal (strong, low).* | 0/2 (0%) | |
| 71. In patients with infection caused by … P. acnes, with associated CSF abnormalities but negative repeat CSF cultures, a new shunt should be reimplanted after 7 days of antimicrobial therapy (strong, low); * if repeat cultures are positive, antimicrobial treatment is recommended until CSF cultures remain negative for 7–10 consecutive days before a new shunt is placed (strong, low). |
0/3 (0%) 1/2 (50%) |
|
| Met all relevant criteria | 0/9 (0%) | |
| Management of Gram-negative bacilli | n=28 |
|---|---|
| 47. For treatment of infection caused by gram-negative bacilli, therapy should be based on in vitro susceptibility testing with agents that achieve good CNS penetration (strong, moderate). | 22/28 (79%) |
| 48. For treatment of infection caused by gram-negative bacilli susceptible to third-generation cephalosporins, ceftriaxone or cefotaxime is recommended (strong, moderate). | 18/22 (82%) |
| 50. For treatment of infection caused by extended-spectrum beta-lactamase–producing gram-negative bacilli, meropenem should be used if this isolate demonstrates in vitro susceptibility (strong, moderate). | 1 / 2 (50%) |
| 60. Infections caused by … 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 (weak, low). | 10–14 days: 7/28 (25%) Up to 21 days: 10/28 (36%) |
| 61. In patients with repeatedly positive CSF cultures on appropriate antimicrobial therapy, treatment should be continued for 10–14 after the last positive culture (strong, low). | 3/15 (20%) |
| 62. Complete removal of an infected CSF shunt and replacement with an external ventricular drain combined with intravenous antimicrobial therapy is recommended in patients with infected CSF shunts (strong, moderate). | 21/28 (75%) |
| 72. In patients with infection caused by … gram-negative bacilli, a new shunt should be reimplanted 10 days after CSF cultures are negative (strong, low). | 1/28 (4%) |
| Met all relevant criteria | 0/28 (0%) |
| Management of Pseudomonas | n=9 |
|---|---|
| 49. For treatment of infection caused by Pseudomonas species, the recommended therapy is cefepime, ceftazidime, or meropenem (strong, moderate)….. | 7/9 (78%) |
| 60. Infections caused by … 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 (weak, low). | 10–14 days: 0/9 (0%) Up to 21 days: 4/9 (44%) |
| 61. In patients with repeatedly positive CSF cultures on appropriate antimicrobial therapy, treatment should be continued for 10–14 after the last positive culture (strong, low). | 0/5 (0%) |
| 62. Complete removal of an infected CSF shunt and replacement with an external ventricular drain combined with intravenous antimicrobial therapy is recommended in patients with infected CSF shunts (strong, moderate). | 7/9 (78%) |
| 72. In patients with infection caused by … gram-negative bacilli, a new shunt should be reimplanted 10 days after CSF cultures are negative (strong, low). | 0/9 (0%) |
| Met all relevant criteria | 0/9 (0%) |
| Management of Acinetobacter | n=0 |
|---|---|
| 51. For treatment of infection caused by Acinetobacter species, meropenem is recommended (strong, moderate),,,, | n/a |
*
2 children did not have methicillin susceptibility reported
†
3 children had no CSF studies obtained
*
1 child had no CSF studies obtained and 1 child had no additional cultures obtained