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Introduction: Ventriculitis, characterized by inflammation of the ventricles in the brain, frequently occurs as a complication of neurosurgical interventions such as the insertion of cerebrospinal fluid (CSF) shunts or external ventricular drains. It can also present as a community-acquired pathology, broadening its clinical significance and complicating diagnosis and treatment. This condition presents significant challenges, primarily due to its association with various medical devices and the predisposing conditions of patients which enhance infection risks. Areas covered: The review comprehensively explores the etiology, risk factors, diagnostic methodologies, and treatment options for ventriculitis. A thorough literature search was conducted, focusing on recent studies, meta-analyses, and clinical reports that discuss the incidence rates, the effectiveness of different management strategies, and the impact of device-related and community-acquired infections. Particular attention is given to the role of CSF drains and shunts, biofilms, and the prophylactic measures employed in clinical settings to mitigate infection risks. Expert opinion: Despite advances in medical technology and infection control protocols, ventriculitis remains a severe complication in both neurosurgical and community settings. The review highlights the need for continued research into innovative diagnostic tools and more effective infection control strategies. [ABSTRACT FROM AUTHOR]

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Background: The diagnosis of meningitis in the infancy period is a challenging. Clinical evaluation and high index of suspicion with early empirical treatment guidelines continue to evolve and support physician efforts to decrease the morbidity and mortality associated with pediatric meningitis. Case report: We report a case of a previously healthy 2-month-old male who presented with excessive crying, preceded by subjective fever and watery diarrhea, for one day without any other symptoms. Parents gave multiple antipyretic doses at home for irritability which might mask his fever. The patient was tachycardic with an unremarkable physical exam. Full septic work-up done after stabilization of the patient and empirical antibiotics started. His blood culture grew Neisseria meningitides which caused meningoencephalitis and ventriculitis with bilateral extra-axial collection, the patient was in septic shock with multiple organ dysfunction. Conclusion: Meningococcal meningitis in the neonatal and infancy periods remains a serious health threat with high morbidity and mortality. This case report urges the physician to keep a high index of suspicion by taking detailed history and frequent assessment in each suspected cases as the clinical presentations, signs and symptoms in the infancy period are not specific nor classic to guide the physician. [SJEMed 2024; 5(2.000): 148-152]

Abstract Background The diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter. Methods An analytic, observational, cross-sectional study was conducted at the University of the Philippines – Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed. Results A total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to

Background: External ventricular drain (EVD)-related infection (ERI) is a common complication in cranial neurosurgery practice with high mortality. The risk factors associated with ERI are not well studied in low- and middle-income countries (LMIC) like India. Identifying the risk variables is a necessity to design robust evidence-based care bundles for ERI prevention. Materials and methods: This is a single-center prospective cohort study. Patients with and without ERI during the 2-year study period were analyzed along with literature review to identify the risk variables associated with ERI. The Institute for Healthcare Improvement (IHI) comprehensive flowchart was used to develop the concept care bundle for ERI prevention. Results: A total of 211 EVD were inserted during the study period. 15 ERI (7.1%) were identified based on IDSA criteria, with an average infection rate of 11.12 per 1000 EVD days. Gram negative bacteria (GNB) were the predominant pathogen (12/15, 80%), with Klebsiella pneumoniae (6/15, 40%) being the most common bacteria isolated. In multivariate analysis, the risk variables associated with ERI were use of broad spectrum pre-surgical antimicrobial prophylaxis for long duration, choice of posterior craniometric points for EVD insertion, EVD duration >7 days, EVD leak and surveillance cerebrospinal fluid (CSF) sampling at periodic intervals. Based on the risk variables identified in this study and literature review, a consensus decision on the care elements for the insertion and maintenance phases was chosen for the concept care bundle for ERI prevention. Conclusion: An evidence-based concept care bundle for ERI prevention is proposed for further multicentric evaluation and validation. [ABSTRACT FROM AUTHOR]

Background: External ventricular drain (EVD) is used for monitoring intracranial pressure or diverting cerebrospinal fluid. However, confirmation of an infection is not immediate and requires obtaining culture results, often leading to the excessive use of antibiotics. This study aimed to compare noninfectious ventriculitis and EVD infection in terms of the risk factors, predictors, prognosis, and effectiveness of care bundle interventions. Methods: This retrospective study was conducted at a medical center with 1,006 beds in northern Taiwan between January 2018 and July 2022. Standard EVD insertion protocols and care bundles have been implemented since 2018, along with the initiation of chlorhexidine. Results: In total, 742 EVD cases were identified. Noninfectious ventriculitis typically presents with fever approximately 8 days following EVD placement, whereas EVD infection typically manifests as fever after 20 days. Aneurysmal subarachnoid hemorrhage was strongly associated with the development of noninfectious ventriculitis (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5–4.4). Alcoholism (adjusted OR 3.5, 95% CI 1.1–12.3) and arteriovenous malformation (adjusted OR 13.1, 95% CI 2.9–58.2) significantly increased the risk of EVD infection. The EVD infection rate significantly decreased from 3.6% (14 of 446) to 1.0% (3 of 219) (p = 0.03) after the implementation of chlorhexidine gluconate bathing. Conclusions: Aneurysmal subarachnoid hemorrhage or fever with neuroinflammation within 2 weeks of EVD placement is indicative of a higher likelihood of noninfectious ventriculitis. Conversely, patients with arteriovenous malformation, alcoholism, or fever with neuroinflammation occurring after more than 3 weeks of EVD placement are more likely to necessitate antibiotic treatment for EVD infection. Chlorhexidine gluconate bathing decreases EVD infection. [ABSTRACT FROM AUTHOR]

Robotic surgery has found increasing use in multiple subfields of neurosurgery. While the initial applications of stereotactic robotic surgery were for the placement of electrodes for extra-operative seizure monitoring, this technique has become increasingly relevant in other areas of neurosurgery. To the best of our knowledge, we report the first case of successful robotic surgery utilization to drain a cerebral abscess and place an external ventricular drain. The authors demonstrate a novel use for stereotactic robotic assistance to drain a cerebral abscess and place ventriculostomy in a 74-year-old female patient who presented with a left basal ganglia Streptococcus intermedius abscess and concomitant ventriculitis. Drainage of a deep-seated abscess and placement of ventriculostomy was successfully performed in this patient without intraoperative difficulties or complications. The total operative time, including registration was 64 minutes and the estimated blood loss was 25 mL. The patient recovered well and was discharged to inpatient rehabilitation on postoperative day 19. The use of robotic surgery to drain cerebral abscesses and place ventriculostomies is technically feasible and may potentially decrease operative time and increase accuracy and safety. [ABSTRACT FROM AUTHOR]

• The use of 16S rRNA PCR indicates that the incidence of VRI is lower than expected. • Definitions of VRI relying on CSF culture are more accurate for diagnosing VRI. • The incidence of abnormal CSF findings in patients with a negative CSF PCR is high. Ventriculostomy-related infections (VRIs) are reported in about 10 % of patients with external ventricular drains (EVDs). VRIs are difficult to diagnose due to clinical and laboratory abnormalities caused by the primary neurological injury which led to insertion of the EVD. Polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF) may enable more accurate diagnosis of VRI. We performed a prospective cohort study to measure the incidence of VRI as diagnosed by 16S rRNA PCR. Patients admitted to intensive care with a primary diagnosis of subarachnoid haemorrhage (SAH), traumatic brain injury (TBI), or intracerebral haemorrhage (ICH), who required an EVD, were assessed for inclusion in this study. Data were extracted from the electronic medical record, bedside charts, or from a prospectively collected database, the Neuroscience Outcomes in Intensive CarE database (NOICE). 16S rRNA PCR was performed on routinely collected CSF as per laboratory protocol. VRI was also diagnosed based on pre-existing definitions. 237 CSF samples from 39 patients were enrolled in the study. The mean patient age was 55.7 years, and 56.4 % were female. The most common primary neurological diagnosis was SAH (61.5 %). The incidence of a positive PCR was 2.6 % of patients (1 in 39) and 0.8 % of CSF samples (2 in 237). The incidence of VRI according to pre-published diagnostic criteria was 2.6 % – 41 % of patients and 0.4 % – 17.6 % of CSF samples. 28.2 % of patients were treated for VRI. Pre-published definitions which relied on CSF culture results had higher specificity and lower false positive rates for predicting a PCR result when compared to definitions incorporating non-microbiological markers of VRI. In CSF samples with a negative 16S rRNA PCR, there was a high proportion of non-microbiological markers of infection, and a high incidence of fever on the day the CSF sample was taken. The incidence of VRI as defined as a positive PCR was lower than the incidence of VRI according to several published definitions, and lower than the incidence of VRI as defined as treatment by the clinical team. Non-microbiological markers of VRI may be less reliable than a positive CSF culture in diagnosing VRI. [ABSTRACT FROM AUTHOR]

Objective: A case of post-neurosurgical ventriculitis caused by a KPC-producing Klebsiella pneumoniae (KPC-Kp) with a ceftazidime/avibactam-resistant, meropenem-susceptible phenotype is reported. Methods and results: The patient had a concomitant bloodstream infection with a wild-type KPC-Kp with a ceftazidime/avibactam-susceptible, meropenem-resistant phenotype. Prolonged treatment with intravenous fosfomycin and meropenem/vaborbactam achieved clinical success.Therapeutic drug monitoring performed during the first days of treatment showed for the first time that vaborbactam efficiently penetrates cerebrospinal fluid. In contrast, meropenem was undetectable in cerebrospinal fluid at each sampling, suggesting that additional doses of meropenem may be required to appropriately prescribe meropenem/vaborbactam for central nervous system infections. Plasma and cerebrospinal fluid levels of fosfomycin were adequate, confirming the potential of this agent possibly even in the fight against multidrug-resistant organisms. Conclusions: This case highlights the need for therapeutic drug monitoring as a crucial tool for optimizing treatment in complicated cases where the pharmacokinetic behaviour of antibiotics is difficult to predict.

Rheumatoid arthritis, an inflammatory rheumatic disease predominantly affecting small limb joints, frequently compromises the cervical spine, resulting in spinal instability and the potential surgical necessity. This may result in severe complications, such as ventriculitis, often associated with a high mortality rate and multidrug-resistant organisms. A major challenge lies in achieving therapeutic antimicrobial concentrations in the central nervous system.

The aetiology of chronic aseptic meningitis is difficult to establish. Candida meningitis in particular is often diagnosed late, as cerebrospinal fluid (CSF) work-up and imaging findings are nonspecific. A 35-year-old patient with chronic aseptic meningitis, for which repeated microbiological testing of CSF was unrevealing, was finally diagnosed with Candida albicans (C. albicans) meningitis with cauda equina involvement using metagenomic nextgeneration sequencing (mNGS). This report highlights the diagnostic challenges and the difficulties of treating shunt-associated fungal meningitis. [ABSTRACT FROM AUTHOR]

Ventriculitis and nosocomial meningitis caused by carbapenem-resistant Gram-negative and vancomycin-resistant Gram-positive bacteria represent a growing treatment challenge. A case of ventriculitis and bacteremia caused by carbapenem-resistant, KPC-producing Klebsiella pneumoniae and vancomycin-resistant Enterococcus faecium in a young woman with acute leukemia who was successfully treated with meropenem/vaborbactam (MVB), rifampicin, and linezolid is described in this paper. This case report emphasizes the importance of a multidisciplinary strategy, including infectious focus control, for the treatment of device-associated central nervous system (CNS) infections from multidrug-resistant bacteria. Considering the novel resistance patterns, more research on drug penetration into the central nervous system, as well as on the necessity of association therapies, is needed. [ABSTRACT FROM AUTHOR]

Background: Hospital-acquired multidrug-resistant (MDR) bacterial meningitis and/or ventriculitis (MEN) is a severe condition associated with high mortality. The risk factors related to in-hospital mortality of patients with MDR bacterial MEN are unknown. We aimed to examine factors related to in-hospital mortality and evaluate their prognostic value in patients with MDR bacterial MEN treated in the neurointensive care unit. Methods: This was a single-center retrospective cohort study of critically ill neurosurgical patients with MDR bacterial MEN admitted to our hospital between January 2003 and March 2021. Data on demographics, admission variables, treatment, time to start of intraventricular (IVT) therapy, and in-hospital mortality were analyzed. Both univariate and multivariable analyses were performed to identify determinants of in-hospital mortality. Results: All 142 included patients received systemic antibiotic therapy, and 102 of them received concomitant IVT treatment. The median time to start of IVT treatment was 2 days (interquartile range 1–5 days). The time to start of IVT treatment had an effect on in-hospital mortality (hazard ratio 1.17; 95% confidence interval 1.02–1.34; adjusted p = 0.030). The cutoff time to initiate IVT treatment was identified at 3 days: patients treated within 3 days had a higher cerebrospinal fluid (CSF) sterilization rate (81.5%) and a shorter median time to CSF sterilization (7 days) compared with patients who received delayed IVT treatment (> 3 days) (48.6% and 11.5 days, respectively) and those who received intravenous antibiotics alone (42.5% and 10 days, respectively). Conclusions: Early IVT antibiotics were associated with superior outcomes in terms of the in-hospital mortality rate, time to CSF sterilization, and CSF sterilization rate compared with delayed IVT antibiotics and intravenous antibiotics alone. [ABSTRACT FROM AUTHOR]

Studies on surgical site infection (SSI) in adult neurosurgery have presented all subtypes of SSIs as the general 'SSI'. Given that SSIs constitute a broad range of infections, we hypothesized that clinical outcomes and management vary based on SSI subtype. A retrospective analysis of all neurosurgical SSI from 2012–2019 was conducted at a tertiary care institution. SSI subtypes were categorized as deep and superficial incisional SSI, brain, dural or spinal abscesses, meningitis or ventriculitis, and osteomyelitis. 9620 craniotomy, shunt, and fusion procedures were studied. 147 procedures (1.5%) resulted in postoperative SSI. 87 (59.2%) of these were associated with craniotomy, 36 (24.5%) with spinal fusion, and 24 (16.3%) with ventricular shunting. Compared with superficial incisional primary SSI, rates of reoperation to treat SSI were highest for deep incisional primary SSI (91.2% vs 38.9% for superficial, p < 0.001) and second-highest for intracranial SSI (90.9% vs 38.9%, p = 0.0001). Postoperative meningitis was associated with the highest mortality rate (14.9%). Compared with superficial incisional SSI, the rate of readmission for intracranial SSI was highest (57.6% vs 16.7%, p = 0.022). Deep incisional and organ space SSI demonstrate a greater association with morbidity relative to superficial incisional SSI. Future studies should assess subtypes of SSI given these differences. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to determine the safety and effectiveness of intraventricular antibiotics in neonates with meningitis and/or ventriculitis and analyze the quality of available evidence. Methods: Design: Systematic review and meta-analysis. Data sources: PubMed, EMBASE, LILACS, and SCOPUS up to 17 February 2023. Eligibility criteria for selecting studies: Randomized experimental and observational studies were included. The Cochrane methodology was used for systematic reviews. Results: Twenty-six observational studies and one randomized clinical trial involving 272 patients were included. The risk of bias in both pediatric and neurosurgical studies was high, and the quality of evidence was low (evidence level C). In the pediatric studies, no significant differences in mortality were found between intraventricular antibiotics and only systemic antibiotic [25.4% vs 16.1%, OR = 0.96 (0.42–2.24), P = 0.93]. However, when analyzing the minimum administered doses, we found a lower mortality when a minimum duration of 3 days for intraventricular antibiotics was used compared to only systemic antibiotic [4.3% vs 17%, OR = 0.22 (0.07–0.72), P = 0.01]. In the neurosurgical studies, the use of intraventricular antibiotics in ventriculitis generally results in a mortality of 5% and a morbidity of 25%, which is lower than that in cases where intraventricular antibiotics were not used, with an average mortality of 37.3% and a morbidity of 50%. Conclusion: Considering the low quality of evidence in pediatric and neurosurgical studies, we can conclude with a low level of certainty that intraventricular antibiotics may not significantly impact mortality in neonatal meningitis and ventriculitis. However, reduced mortality was observed in cases treated with a minimum duration of 3 days of intraventricular antibiotic, particularly the multidrug-resistant or treatment-refractory infections. Higher-quality studies are needed to improve the quality of evidence and certainty regarding the use of intraventricular antibiotics for treating neonatal meningitis and ventriculitis. [ABSTRACT FROM AUTHOR]

The external ventricular drain (EVD) is an important instrument in managing patients in neurointensive care (NICU). A frequent and sometimes severe complication is ventriculostomy-related infection (VRI). This study aimed to evaluate the effects of biweekly VRI screening by CSF sampling on the clinical course and rate of VRI. Patients with implanted EVDs were retrospectively identified and a cohort screened twice per week was compared with a cohort sampled only on clinical indication. VRI was defined either as a suspected case or a culture-confirmed case. Length of stay in the NICU and CSF shunt dependency were used as outcome parameters. A total of 562 patients were included. The overall proportion of patients treated for VRI was 22% and was not affected by screening (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.57–1.54). Screening was associated with a higher proportion of patients with culture-confirmed VRI (OR, 2.86; 95% CI, 1.36–6.73). The main risk factor for VRI was the number of days with EVD. Positive bacterial culture was associated with both a longer time in the NICU (β = 3.6; P < 0.01) and higher risk for shunt surgery (OR, 1.95; 95% CI, 1.04–3.64). Screening was associated with a higher number of culture-confirmed VRI cases. In addition, screening did not detect VRI at an earlier stage and was not associated with a reduction in the rate of permanent hydrocephalus. No clinical benefit of screening was found. Frequent CSF sampling might contribute to infection. Based on these findings, CSF screening for VRI cannot be recommended. [ABSTRACT FROM AUTHOR]

A wide variety of community- and hospital-associated infections of the central nervous system (CNS) may be encountered on the neurointensive care unit (NICU). Distinguishing between the potential infectious aetiologies and differentiating from non-infectious causes can be challenging. Specific elements of the history and establishing early the immune status and travel history of an individual with possible infection can guide targeted additional testing. Increasing prevalence of iatrogenic immunosuppression means that familiar pathogens can present atypically. In addition, epidemiology of pathogens is changing with rising antimicrobial resistance and autochthonous cases of previously travel-associated pathogens. [ABSTRACT FROM AUTHOR]

Nosocomial central nervous system (CNS) infections with carbapenem- and colistin-resistant Gram-negative and vancomycin-resistant Gram-positive bacteria are an increasing therapeutic challenge. Here, we review pharmacokinetic and pharmacodynamic data and clinical experiences with new antibiotics administered intravenously for the treatment of CNS infections by multi-resistant bacteria. Cefiderocol, a new siderophore extended-spectrum cephalosporin, pharmacokinetically behaves similar to established cephalosporins and at high doses will probably be a valuable addition in our therapeutic armamentarium for CNS infections. The new glycopeptides dalbavancin, telavancin, and oritavancin are highly bound to plasma proteins. Although effective in animal models of meningitis, it is unlikely that they reach effective cerebrospinal fluid (CSF) concentrations after intravenous administration alone. The β-lactam/β-lactamase inhibitor combinations have the principal problem that both compounds must achieve adequate CSF concentrations. In the commercially available combinations, the dose of the β-lactamase inhibitor tends to be too low to achieve adequate CSF concentrations. The oxazolidinone tedizolid has a broader spectrum but a less suitable pharmacokinetic profile than linezolid. The halogenated tetracycline eravacycline does not reach CSF concentrations sufficient to treat colistin-resistant Gram-negative bacteria with usual intravenous dosing. Generally, treatment of CNS infections should be intravenous, whenever possible, to avoid adverse effects of intraventricular therapy (IVT). An additional IVT can overcome the limited penetration of many new antibiotics into CSF. It should be considered for patients in which the CNS infection responds poorly to systemic antimicrobial therapy alone. [ABSTRACT FROM AUTHOR]

Background: Cerebral abscesses complicated by ventriculitis present significant treatment challenges, often associated with high morbidity and mortality. Traditional management approaches, including systemic antibiotic therapy and external ventricular drainage (EVD), face limitations due to the blood-brain barrier and risks of catheter-related complications. This report discusses a case where the dual-lumen catheter system, an innovative neurosurgical tool integrating continuous irrigation with drainage, was employed. Case Description: A patient presented with a cerebral abscess ruptured into the ventricle, leading to ventriculitis. Conventional treatment options were limited due to the abscess's deep and eloquent location and the associated risk of complications from standard EVD. The dual lumen system was chosen for its ability to provide continuous irrigation and drainage, effectively addressing issues of catheter blockage and enhancing localized antibiotic delivery. The system was used to create a single stereotactic tract for simultaneous treatment of the abscess and ventriculitis. This approach allowed for a more controlled and effective treatment process, resulting in rapid resolution of the conditions without chronic hydrocephalus development or further complications. Conclusion: The use of the dual lumen system represented a significant advancement in this case, addressing the limitations of conventional treatments. Its ability to maintain intracranial pressure within optimal limits while providing localized, continuous treatment was pivotal. This case highlights the potential of the dual lumen catheter in managing complex neurosurgical infections and underscores the need for further research to establish its efficacy in broader clinical applications. [ABSTRACT FROM AUTHOR]

The aetiology of chronic aseptic meningitis is difficult to establish. Candida meningitis in particular is often diagnosed late, as cerebrospinal fluid (CSF) work-up and imaging findings are nonspecific. A 35-year-old patient with chronic aseptic meningitis, for which repeated microbiological testing of CSF was unrevealing, was finally diagnosed with Candida albicans (C. albicans) meningitis with cauda equina involvement using metagenomic next-generation sequencing (mNGS). This report highlights the diagnostic challenges and the difficulties of treating shunt-associated fungal meningitis.

Objectives: Nosocomial ventriculitis is a difficult infectious condition to diagnose given that typical cerebral spinal fluid (CSF) parameters, commonly used in the diagnosis of meningitis, lack sensitivity and specificity in nosocomial ventriculitis. Consequently, novel diagnostics are needed to aid in diagnosing this condition. Herein a pilot study using alpha-defensins (α-defensins) to diagnose ventriculitis is discussed. Methods: From May 01, 2022, to December 30, 2022, ten patients with culture-proven external ventricular drain (EVD)-associated ventriculitis and ten patients without EVD-associated ventriculitis had CSF preserved. Levels of α-defensins were compared between the two cohorts with enzyme-linked immunosorbent assay. Results: There was a statistically significant (P ˂0.0001) higher level of CSF α-defensins in the ventriculitis cohort compared to the non-ventriculitis cohort. The levels of α-defensins were not affected by blood in CSF or bacterial virulence. Patients with other infectious conditions had increased levels of α-defensins but these levels were still statistically significantly (P ˂0.001) less than those seen in the ventriculitis cohort. Conclusion: This pilot study shows that α-defensins have promise as a biomarker to aid in the diagnosis of ventriculitis. If larger studies support the findings here, this biomarker can help improve diagnostic accuracy and decrease unwarranted empirical broad-spectrum antibiotic use in suspected EVD-associated ventriculitis.

Introduction: Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality. Methods: Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution. Results: Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0–2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/− 0.8). Conclusions: Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection. [ABSTRACT FROM AUTHOR]

Enterococcus-associated ventriculitis and meningitis are rare manifestations of enterococcal infection, but they are an infection with dire consequences in patients with neurosurgical pathology, since despite the availability of a large number of antibacterial drugs, the optimal approach to the treatment of enterococcal ventriculitis has not currently been established. In this article we present a description of a clinical case of a 1 year and 4 month old child who was hospitalized with signs of dysfunction of the shunt system and intoxication. During the audit of the shunt system, dysfunction of the ventricular end of the shunt system was discovered. In the postoperative period, the patient showed signs of ventriculitis, and bacteriological examination of the cerebrospinal fluid revealed Enterococcus durans. After combined antibacterial therapy for enterococcus-associated ventriculitis, the ventriculoperitoneal shunt was reinstalled. During treatment for bacterial ventriculitis, the patient developed signs of disseminated intravascular coagulation (DIC), which were relieved with hemostatic drugs and transfusion of blood components. The patient was safely discharged with improvement thanks to effective combination antibacterial therapy, timely detection and treatment of DIC syndrome. Thus, if there are signs of ventriculitis in a patient with a ventriculoperitoneal shunt, it is extremely important to identify the cause of inflammation and exclude possible dysfunction of the shunt system. And during the selection of treatment tactics, in order to achieve higher concentrations of the antibiotic in the cerebrospinal fluid, one should consider the use of combination antibacterial therapy as a more effective way to treat bacterial ventriculitis. [ABSTRACT FROM AUTHOR]

Twenty-four American white ibis (Eudocimus albus) nestlings were collected in Florida (USA) on 17 April 2017 to establish a captive flock. On 7 May 2017, three birds died suddenly, following severe lethargy, hemorrhaging from the mouth and nares, anorexia, and production of bright-green colored feces. An additional ibis with delayed growth and pathological fractures was euthanized 18 May 2017. Severe ventriculitis associated with Macrorhabdus ornithogaster was noted in all four birds, bacterial sepsis was confirmed in one bird by culture and histologic examination, and bacterial endotoxemia was suspected in two birds based on gross and histologic examination, but no bacteria were isolated from these birds. Birds also had vitamin E liver levels consistent with coagulopathy previously described in pelicans. We sampled feces from 91 adult, free-living, healthy ibis in Florida in July 2017 and found 71% were shedding organisms with morphologic characteristics consistent with Macrorhabdus sp. Molecular characterization of the ibis-origin M. ornithogaster showed it was phylogenetically related to numerous M. ornithogaster sequences. It is unknown if M. ornithogaster infection resulted in clinical disease as a result of dietary or stress-related dysbiosis, or other factors. Macrorhabdus-associated disease has not previously been confirmed in wading birds. We discuss potential associations of gastric M. ornithogaster infection with morbidity and mortality in these cases and highlight the need for additional studies on this pathogen in free-living birds. [ABSTRACT FROM AUTHOR]

Ventriculitis and nosocomial meningitis caused by carbapenem-resistant Gram-negative and vancomycin-resistant Gram-positive bacteria represent a growing treatment challenge. A case of ventriculitis and bacteremia caused by carbapenem-resistant, KPC-producing Klebsiella pneumoniae and vancomycin-resistant Enterococcus faecium in a young woman with acute leukemia who was successfully treated with meropenem/vaborbactam (MVB), rifampicin, and linezolid is described in this paper. This case report emphasizes the importance of a multidisciplinary strategy, including infectious focus control, for the treatment of device-associated central nervous system (CNS) infections from multidrug-resistant bacteria. Considering the novel resistance patterns, more research on drug penetration into the central nervous system, as well as on the necessity of association therapies, is needed.

Neurobrucellosis is a serious focal brucella infection. Ventriculitis is a special form of central nervous infection where pyogenic infection of the ependymal linings hinders antibiotics' accessibility to the cerebrospinal fluids and leads to protracted infection. We present a case of a 37-year-old Shepherd who had low-grade fever for 5 months followed by a brief history of vomiting, abdominal pain, and gait imbalance. Investigations showed neutrophilic leukocytosis, high titers of serum anti-brucella antibodies, and lymphocytic pleocytosis. Mycobacterial tuberculosis workup was negative. Magnetic resonance imaging of the brain revealed cervical and spinal meningeal enhancement in addition to mild hydrocephalus. The patient was presumptively diagnosed with neurobrucellosis. He received treatment with ceftriaxone-based combination antibiotics therapy for 6 months with complete resolution of his symptoms. Central nervous infection by brucella is a challenging diagnosis. The possibility of primary ventriculitis due to Brucella infection mandates early recognition and prolonged antimicrobial therapy to achieve full recovery. [ABSTRACT FROM AUTHOR]

We compared external ventricular drains (EVDs) with percutaneous continuous cerebrospinal fluid (CSF) drainage via ventricular access devices (VADs) for the acute management of hydrocephalus in adults. This was a retrospective review of all ventricular drains inserted for a new diagnosis of hydrocephalus into noninfected CSF over four years. We compared infection rates, return to theatre, and patient outcome between EVDs and VADs. We explored the effect of duration of drainage, frequency of sampling, hydrocephalus aetiology, and catheter location on these outcomes using multivariable logistic regression modelling. We included 179 drains (76 EVDs and 103 VADs). EVDs were associated with a higher rate of unplanned return to theatre for replacement or revision (27/76, 36%, vs. 4/103, 4%, OR: 13.4 95%CI: 4.3–55.8). However, infection rates were higher in VADs (13/103, 13% vs. 5/76, 7%, OR: 2.0, 95%CI: 0.65–7.7). EVDs were 91% antibiotic impregnated whereas VADs were 98% nonimpregnated. In multivariable analysis, infection was associated with duration of drainage (median: 11 days prior to infection for infected drains vs. 7 days total for noninfected drains), but not drain type (VADs vs. EVDs OR: 1.6, 95%CI: 0.5–6). EVDs had a higher rate of unplanned revisions but a lower infection rate compared to VADs. However, in multivariable analysis choice of drain type was not associated with infection. We suggest a prospective comparison of antibiotic impregnated VADs and EVDs using similar sampling protocols to assess whether VADs or EVDs for acute hydrocephalus have a lower overall complication rate. [ABSTRACT FROM AUTHOR]

Introduction Nosocomial ventriculitis is a severe infection that habitually plagues neurological intensive care units. It is usually associated with external ventricular drains. Unfortunately, classic cerebral spinal fluid parameters are less specific and sensitive compared to community acquired meningitis. This is in part secondary to indolent bacteria commonly infecting external ventricular drains leading to ventriculitis. Case report Herein, a rare case of Sphingomonas paucimobilis ventriculitis in an immunocompetent host is reported. The patient had classic symptoms of ventriculitis, but her cerebral spinal fluid parameters were benign and initial cultures were negative. Consequently, treatment was tailored to an assumed respiratory infection only to have recurrence of her symptoms. Repeat analysis of her cerebral spinal fluid was again benign, but her cerebral spinal fluid culture grew S. paucimobilis. Subsequently, the patient was treated with cefepime, which resolved her symptoms. She completed a two-week course and has had no recurrence of her infection. Conclusions This case reinforces the need for clinicians to have heightened awareness of this emerging pathogen, its antibiotic resistance patterns, and the unique composition of this bacterium's cell wall which has ramifications on disease presentation. [ABSTRACT FROM AUTHOR]

• Conventional ventriculitis diagnostics lack sensitivity and specificity. • Alpha-defensins are a novel diagnostic that can aid in diagnosing ventriculitis. • Significantly higher levels of α-defensins were present in the ventriculitis cohort. • Levels of α-defensins were not affected by blood or species of bacteria. Nosocomial ventriculitis is a difficult infectious condition to diagnose given that typical cerebral spinal fluid (CSF) parameters, commonly used in the diagnosis of meningitis, lack sensitivity and specificity in nosocomial ventriculitis. Consequently, novel diagnostics are needed to aid in diagnosing this condition. Herein a pilot study using alpha-defensins (α-defensins) to diagnose ventriculitis is discussed. From May 01, 2022, to December 30, 2022, ten patients with culture-proven external ventricular drain (EVD)-associated ventriculitis and ten patients without EVD-associated ventriculitis had CSF preserved. Levels of α-defensins were compared between the two cohorts with enzyme-linked immunosorbent assay. There was a statistically significant (P ˂0.0001) higher level of CSF α-defensins in the ventriculitis cohort compared to the non-ventriculitis cohort. The levels of α-defensins were not affected by blood in CSF or bacterial virulence. Patients with other infectious conditions had increased levels of α-defensins but these levels were still statistically significantly (P ˂0.001) less than those seen in the ventriculitis cohort. This pilot study shows that α-defensins have promise as a biomarker to aid in the diagnosis of ventriculitis. If larger studies support the findings here, this biomarker can help improve diagnostic accuracy and decrease unwarranted empirical broad-spectrum antibiotic use in suspected EVD-associated ventriculitis. [ABSTRACT FROM AUTHOR]

Abstract Background External ventricular drainage (EVD) is frequently used in neurosurgical procedures for cerebrospinal fluid (CSF) drainage. It is, however, associated with high infection rates, namely secondary meningitis and ventriculitis. Based on a previous high prevalence of these infections among patients with EVDs, we have proposed and implemented a protocol in an effort to decrease the infection rate. The aim of this study was to measure the effect of hospital-wide implementation of the EVD handling protocol on secondary EVD infections. Patients and methods We included 409 consecutive patients who received a new EVD for other indications than infectious pathologies from January 2000 until June 2012. Patients above 18 years of age were divided into pre- (n = 228) and post-protocol (n = 181) groups. Patient and disease demographics, as well as EVD data together with confounders for secondary meningitis were recorded in a database. Propensity score matching was then performed to create groups matched for sex, age, reason for drainage, type of shunt, time in situ and duration of surgery to place the EVD. Binomial logistic regression for confounder adjustment and regression discontinuity analyses were then performed on the matched cohort. Results Infections occurred more frequently in the pre-protocol group (23% vs 9%, p

The COVID-19 pandemic has had a major global impact on the treatment of hospitalized surgical patients. Our study retrospectively evaluates the impact of the COVID-19 pandemic at a neurosurgical reference center in Mexico City. We compared the number of neurosurgeries, the rate and type of postoperative infections, the causative microorganisms and in-hospital mortality rates in a 4-year period, from the pre-pandemic year 2019 until 2022. A total of 4150 neurosurgical procedures were registered. In 2020 the total number of surgeries was reduced by 36% compared to 2019 OR = 0.689 (95% CI 0.566–0.834) p ≤ 0.001, transnasal/trans sphenoidal pituitary resections decreased by 53%, and spinal surgeries by 52%. The rate of neurosurgical infections increased from 3.5% in 2019 to 5.6% in 2020 (p = 0.002). Regarding the microorganisms that caused infections, gram positive cocci accounted for 43.5% of isolates, Klebsiella spp. and Pseudomonas spp. caused one third of the infections. No significant differences were found for in-hospital mortality nor patterns of resistance to antibiotics. The number of surgeries increased in the last two years, although the infection rate has returned to pre-pandemic levels. We observed a lower impact from subsequent waves of COVID-19 and despite an increase in the number of surgeries, the surgeries have not amounted to the full pre-pandemic levels. [ABSTRACT FROM AUTHOR]

Ventriculitis is a severe complication of indwelling neurosurgical devices that is associated with significant morbidity and mortality. The incidence rate of ventriculitis is approximately 10% with external ventricular drains. Obstinately, patients with these indwelling neurosurgical devices are prone to have traditional cerebral spinal fluid parameters that lack sensitivity and specificity in diagnosing nosocomial ventriculitis. In addition, diagnosis can be arduous given that indolent pathogens are commonly implicated. Therefore, diagnosis is difficult but paramount to thwart the morbidity and mortality associated with this infectious condition as well as to reduce the prolonged use of broad-spectrum antibiotics. As we extrapolate from prosthetic joint infections, for which diagnosis can also be challenging, we learn that the use of α-defensins as a diagnostic biomarker for nosocomial ventriculitis may hold promise. Herein, the viewpoint of using α-defensins as a diagnostic biomarker for nosocomial ventriculitis is discussed. [ABSTRACT FROM AUTHOR]

The primary aim of this study was to review the diagnosis, management and outcome of Candida meningitis/ventriculitis in our hospital over a ten-year period. We retrospectively reviewed all culture and 18s rRNA nucleic acid positive CSF specimens processed between 1st January 2010 and 31st December 2020. Patient records were subsequently reviewed to assess the significance of the isolate. Of 851 culture-positive cerebrospinal fluid (CSF) specimens, Candida spp. were isolated from 29 (3.4%), representing infection in 12 patients. One culture-negative specimen was positive for Candida on 18s rRNA testing. Of the 13 patients, eight were male; 61.5% and the median age was 47 years; range: 20–70. The median interval from admission to onset of infection and culture positivity was 24 days (range: 1–63 days). All patients had a central nervous system (CNS) device in situ (external ventricular drain: 11; ventriculoperitoneal shunt: 1; lumbar drain: 1). Four were colonised with Candida spp. before meningitis/ventriculitis diagnosis, from wounds (n = 3), respiratory (n = 3), and urine (n = 1) specimens. On culture, the most common species was Candida albicans (n = 8), followed by C. parapsilosis (n = 2), C. tropicalis (n = 1), and C. dubliniensis (n = 1). The median number of follow-up CSFs per patient was nine (range; 3–22), with a median of 6 days to CSF sterility (range 3–10 days). Treatment included; liposomal amphotericin B (n = 5), fluconazole (n = 2), liposomal amphotericin B, and flucytosine (n = 2), liposomal amphotericin B, fluconazole and flucytosine (n = 3), and intra-ventricular amphotericin B (n = 1). Median treatment duration was 25 days (range 11–76) and CNS device removal occurred in 12 patients. The median length-of-stay (LOS) was 58 days (range 24–406). On discharge, moderate to severe disability (Modified Rankin Scale [mRS] 3–5) was evident in eight patients. Two patients died and one was lost to follow-up. Meningitis/ventriculitis due to Candida spp. is an uncommon but challenging infection, usually associated with a device, increased morbidity, LOS, and necessitating prolonged treatment. Neurosurgeons need to be aware of these issues in managing and in communicating with such complex patients. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the risk of central nervous system (CNS) infections in children undergoing neurosurgery for brain tumors. Methods: Single-center retrospective cohort study including all children with brain tumors undergoing neurosurgical treatment over an 11-year period. Results: A total of 274 patients undergoing 733 neurosurgical procedures were included. Overall, 12.8% of patients were diagnosed with a CNS infection during their course of treatment. CNS infections were more frequent among children treated with CSF diversion (p < 0.001) and independently associated with low age (OR/y 0.9 (CI 95% 0.769–0.941), intraventricular (OR 2.8, CI 95% 1.2–6.5), and high-grade tumors (OR 2.7, CI 95% 1.1–6.5). The majority of CNS infections occurred within 30 days of surgery, resulting in a postoperative CNS infection rate of 5.3%. Postoperative CNS infections were significantly more frequent following adjunct EVD placement during tumor resection compared to a stand-alone craniotomy (30.4% vs. 1.5%, RR 20.6, CI 95% 5.7–72.2). Conclusion: CNS infections affect at least 12% of children with brain tumors and are associated with age, tumor location, and grade. Adding EVD to tumor surgery increases the risk of postoperative CNS infection, and reconsidering routine adjunct EVD placement is therefore advocated. [ABSTRACT FROM AUTHOR]

Background: External ventricular drainage (EVD) is frequently used in neurosurgical procedures for cerebrospinal fluid (CSF) drainage. It is, however, associated with high infection rates, namely secondary meningitis and ventriculitis. Based on a previous high prevalence of these infections among patients with EVDs, we have proposed and implemented a protocol in an effort to decrease the infection rate. The aim of this study was to measure the effect of hospital-wide implementation of the EVD handling protocol on secondary EVD infections. Patients and methods: We included 409 consecutive patients who received a new EVD for other indications than infectious pathologies from January 2000 until June 2012. Patients above 18 years of age were divided into pre- (n = 228) and post-protocol (n = 181) groups. Patient and disease demographics, as well as EVD data together with confounders for secondary meningitis were recorded in a database. Propensity score matching was then performed to create groups matched for sex, age, reason for drainage, type of shunt, time in situ and duration of surgery to place the EVD. Binomial logistic regression for confounder adjustment and regression discontinuity analyses were then performed on the matched cohort. Results: Infections occurred more frequently in the pre-protocol group (23% vs 9%, p < 0.001). The incidence of infection was 33/1000 drain-days pre-protocol and 9/1000 drain-days post-protocol. Regression analysis in a propensity score-matched cohort (n = 103 in the pre- and n = 178 in the post-protocol groups) showed that the pre-protocol period was independently associated with more infections (OR 2.69; 95%-CI 1.22–5.95, p = 0.01). Conclusions: The incidence of secondary EVD infections can be reduced significantly by the implementation of a strict hospital-wide EVD handling protocol. [ABSTRACT FROM AUTHOR]

Background: Enterococcal infections are increasingly common in hospitalized patients. Enterococcal meningitis/ventriculitis (EMV) is an extremely rare condition of enterococcal infections, occurring particularly in children. This study investigated the clinical and microbiological characteristics, predisposing factors, and prognosis in pediatric patients with EMV. Methods: Pediatric patients (<18 years) diagnosed with EMV were retrospectively evaluated over 10 years. Results: The study included a total of 25 isolates from 24 patients, median age 23 months (range: 1–136 months). The most common symptoms included vomiting, fever, and headache, with hydrocephalus shunt and preterm birth being the two most common conditions. Commonly associated infections, with central nervous system (CNS) devices as a predisposing factor, were due to external ventricular drainage and ventriculoperitoneal shunts. Two patients with spontaneous meningitis were preterm infant. Of the isolates, 44% were Enterococcus faecalis, 44% E. faecium, and 12% E. gallinarum. Five (20%) isolates were vancomycin resistant. Twelve patients were resistant to anti‐enterococcal antibiotics, including ampicillin, ciprofloxacin, imipenem, teicoplanin, gentamicin, and linezolid (40%, 20%, 8%, 8%, 4%, and 4%, respectively). Enterococcus faecium was more resistant to ampicillin, ciprofloxacin, teicoplanin, and vancomycin than E. faecalis. The median treatment duration was 17 days (interquartile range: 14–26 days).The mortality rate was 8.3% (2/24; both associated with vancomycin resistance). Conclusions: Neurosurgical conditions are the most common predisposing factors for EMV. Preterm birth is an important predisposing factor in children. Because EMV is nonspecific in clinical findings, it should be considered when there is an underlying CNS disorder and empirical treatment should begin in this direction. [ABSTRACT FROM AUTHOR]

Marios Karvouniaris,1 Alexandros Brotis,2 Konstantinos Tsiakos,3 Eleni Palli,4 Despoina Koulenti5,6 1Intensive Care Unit, AHEPA University Hospital, Thessaloniki, Greece; 2Neurosurgery Department, University Hospital of Larissa, Larissa, Greece; 3Third Department of Internal Medicine, “Sotiria” Hospital, Athens, Greece; 4Intensive Care Unit, University Hospital of Larissa, Larissa, Greece; 5Second Critical Care Department, Attikon University Hospital, Athens, Greece; 6UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, AustraliaCorrespondence: Marios Karvouniaris, ACHEPA University Hospital, S.Kiriakidi 1, Thessaloniki, 54636, Greece, Tel +302313303645, Fax +302313303096, Email karvmarevg@hotmail.comAbstract: Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.Keywords: ventriculitis, cerebrospinal fluid, external ventricular drain, molecular diagnostics, antibiotic penetration, intraventricular treatment

Traumatic ventriculitis or hardware disease is the gizzard perforation by sharp foreign bodies (metallic or sharp object) that leads to ulcerative lesions.The present Case Report was to investigate through post mortem examination the cause of African ostrich death. Necropsy was conducted on a dead male adult African Ostrich presented to the postmortem unit of the Department of Veterinary Pathology, University of Ilorin, Ilorin, Nigeria. The gross lesions showed multifocal ecchymotic and petechial haemorrhages and lacerations on the left shank and thigh as well as the cloaca and vent of the bird. A perforation of the proventriculus with adhesion of a pointed nail-like metallic sharp object of 9.4 cm in length was observed. Histopathological findings revealed obliteration of tubular and vascular congestion which predisposed the animal to metabolic disorder.

Although well described in the current literature, Neurocysticercosis [NCC] remains an enigma when confronted by practitioners. This is in part due to the haphazard nature of the parasitic infection on the central nervous system [CNS]. These include single or multiple anatomic sites of infection, stage of parasitosis, and the resultant inflammatory response. As a result, NCC can present with a complex constellation of symptomatic presentations, making therapeutic regiments highly individualized. Despite intervention, other impediments may arise post-therapy due to the nature of the infection. We present a case of rapidly progressive symptomatic NCC that initially was successfully treated, however would eventually succumb to complications of ventriculitis.

Health care- and device-associated central nervous system (CNS) infections have a distinct epidemiology, pathophysiology, and microbiology that require a unique diagnostic approach. Most clinical signs, symptoms, and tests used to diagnose community-acquired CNS infections are insensitive and nonspecific in neurosurgical patients due to postsurgical changes, invasive devices, prior antimicrobial exposure, and underlying CNS disease. The lack of a standardized definition of infection or diagnostic pathway has added to this challenge. In this review, we summarize the epidemiology, microbiology, and clinical presentation of these infections, discuss the issues with existing microbiologic tests, and give an overview of the current diagnostic approach.

Introduction Neural tube defects constitute a major source of disability among children. Proper management requires accurate diagnosis, an assessment of the severity of the lesion, a decision whether intervention is warranted, the nature of the intervention, and educating the family of the need for lifelong medical care. But to do so, reliable data regarding presentation and outcome is very crucial. Aim of the study To discuss the clinical epidemiological profile and outcome of babies admitted with neural tube defects (NTDs). Material and methods Retrospective observational study was done by extracting data from case notes and follow-up files in Department of Neonatology, PGIMER and Dr. RML Hospital, New Delhi over a period from March 2015 to July 2020. Results A total of 25 babies were included in the study. Majority of babies were born to mother at a median age group of 24 (19–36) yrs and nearly one-third of them were illiterate. The history of maternal periconceptional folic acid intake was seen in only five babies (21%). Two third of babies were male (64%) and the median age at admission was at 9 (1–27) days of life. Majority of the cases were open types of NTDs with most common type being meningomyelocele (88%) followed by occipital encephalocele (12%) and there was one case of closed type of neural tube defect having lipomeningomyelocele (4%). The most common associated anomaly was hydrocephalus (76%) followed by Arnold chiari malformation (56%). Motor weakness in form of paraparesis or paraplegia was present in 21 (84%) babies and sensory deficit was present in 44% babies. Bowel and bladder dysfuntion was present in 48% of cases. Ventriculitis was the most common associated morbidity (38%). Meningomyelocele (MMC) repair was the most commonly performed primary surgery (33%) followed by Ventriculo-peritoneal (VP) shunt repair (24%). Twelve babies (48%) were discharged while 2 (8%) expired and 11 (44%) babies left against medical advice Conclusion Neural tube defect is a congenital disorder with significant morbidity. The clinical severity of the NTDs and the uncertainty in their cause makes this a priority for further research. National policies for prevention, in utero diagnosis, and early surgical intervention are required for a better prognosis. [ABSTRACT FROM AUTHOR]

Introduction: External ventricular drain (EVD) associated ventriculitis is a complication of EVD placement associated with significant morbidity and mortality. Gold‐standard for EVD associated bacterial ventriculitis diagnosis involves cerebrospinal fluid (CSF) sampling from the EVD with microscopy, culture and sensitivity testing. The ratio of white blood cells to red blood cells has anecdotally been considered a predictive factor in diagnosing EVD associated ventriculitis, however no study has been done demonstrating this. Methods: A retrospective cross‐sectional study was designed to assess whether the ratio of CSF white blood cells to red blood cells could be used to diagnose EVD associated ventriculitis. Data was collected for all patients undergoing EVD insertion at a major neurosurgical unit in Sydney, Australia. A receiver operator characteristics (ROC) curve was used to determine if this ratio was useful, and Youden's index was calculated to determine the appropriate cut‐off point. Results: This sample of n = 157 consecutive patients a total of 29 patients were diagnosed with ventriculitis. The area under the ROC curve was significant (0.706, P <0.001), and Youden's index demonstrated an appropriate cut‐off point was a ratio of 1:106. Discussion: CSF parameters have long been considered predictive of EVD associated ventriculitis. We demonstrated that using a component of routine testing it is possible to accurately predict a ventriculitis diagnosis. As the ratio is used, it enables discrimination in a raised white blood cell count due to local trauma with interventricular bleeding. Conclusion: CSF white blood cell to red blood cell ratio is an appropriate diagnostic test for ventriculitis. [ABSTRACT FROM AUTHOR]

Bacterial central nervous system (CNS) infections are serious and carry significant morbidity and mortality. They encompass many syndromes, the most common being meningitis, which may occur spontaneously or as a consequence of neurosurgical procedures. Many classes of antimicrobials are in clinical use for therapy of CNS infections, some with established roles and indications, others with experimental reporting based on case studies or small series. This review delves into the specifics of the commonly utilized antibacterial agents, updating their therapeutic use in CNS infections from the pharmacokinetic and pharmacodynamic perspectives, with a focus on the optimization of dosing and route of administration that have been described to achieve good clinical outcomes. We also provide a concise synopsis regarding the most focused, clinically relevant information as pertains to each class and subclass of antimicrobial therapeutics. CNS infection morbidity and mortality remain high, and aggressive management is critical in ensuring favorable patient outcomes while averting toxicity and upholding patient safety. [ABSTRACT FROM AUTHOR]