Page updated 30 April 2007
Post-operative Bacterial Ventriculitis
Ventriculitis or meningitis following neurosurgery occurs in between 0.5 and 5% of cases. The common organisms are Staphylococcus epidermidis, Staphylococcus aureus and sometimes Gram-negatives. Optimal treatment is achieved using intraventricular vancomycin and/or gentamicin given through an external intraventricular drain (EVD).
Management of Ventriculitis
- Do not sample ventricular CSF unless there is a clinical indication or the patient needs intraventricular antibiotics.
- Take samples and give antibiotics via the 3-way tap using aseptic technique.
- Antibiotics: Gentamicin and amikacin can be given into the ventricular and other (eg lumbar) subarachnoid space. Vancomycin and amphotericin B can only be given into the ventricles (risk of arachnoiditis if given into the spinal CSF).
- The usual dose of gentamicin is 5mg and of vancomycin 10mg given once daily.
- The usual hold time after putting in antibiotics is 1h.
- Maintain antibiotics in the ventricles by raising bag above the level of the head.
- Sample daily to monitor CSF cell counts and bacteriology.
- If ventriculitis fails to resolve, replace EVD and give the antibiotics twice a day and hold for 2 hours.
- Replace the EVD weekly.
- Continue antibiotics until cell count is consistently low (<20 cells/cu mm) and CSF culture negative.
- Stop the antibiotics and if the CSF cell count remains low for 3 days, plan insertion of a permanent shunt.
Note that CSF samples are enriched for 5 days in the laboratory to detect small numbers of damaged organisms.
Systemic vancomycin and vancomycin do not penetrate the blood-brain barrier, so should not be given in addition to the intraventricular antibiotics unless there is evidence of infection outside the subarachnoid space.
Permanent Shunt Insertion After Ventriculitis
- Wait until cell counts consistently low, no organisms seen and enrichment cultures negative off antibiotics.
- Leave for at least 3 days with daily sampling.
- Procedure first on the list.
- Operation to be performed by the most experienced surgeon available.
- Dose of appropriate antibiotic to be given intraventricularly at the time of the procedure.
- No visitors in theatre.
- Use long tunnel if possible.
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