Efficacy and safety of intraventricular polymyxin B plus continuous ventricular drainage for the treatment of intracranial infection caused by drug-resistant Acinetobacter baumannii.

BACKGROUND: The bacterial resistance rate has risen in recent years, and polymyxin B has been used more frequently to treat severe intracranial infection. This study aimed to investigate the clinical efficacy and safety profiles of intraventricular polymyxin B plus continuous ventricular drainage for the treatment of intracranial infection caused by drug-resistant Acinetobacter baumannii (DR-AB). METHODS: A retrospective study was performed on 21 patients who had an intracranial infection caused by DR-AB after neurosurgery at our hospital from May 2017 to July 2020. These patients were treated by intraventricular polymyxin B plus continuous ventricular drainage. The clinical features, treatment, cerebrospinal fluid (CSF)-related indicators, outcomes, and prognosis of these patients were analyzed. RESULTS: The external drainage tubes inserted into the lateral ventricle were kept unobstructed in all 21 patients. These patients received intraventricular polymyxin B 5 mg/day plus intravenous antibiotics. The treatment with intraventricular polymyxin B lasted for 18.19±12.36 days. The time to positive CSF culture was 10.50±10.60 days. The bacterial clearance rate of CSF was 95.2% (20/21). The clinical cure rate was 81.0% (17/21), and the mortality rate was 19.0% (4/21). As for the causes of death, 1 case died from purulent CSF with cerebral abscess, which was considered to be caused by extensive brain parenchymal infection, 2 cases died from spontaneous intraventricular hemorrhage after returning negative for CSF cultures, and 1 case died from secondary massive cerebral infarction after returning negative for CSF cultures. There were no significant changes in the serum creatinine level before and after treatment. CONCLUSIONS: For intracranial infection caused by DR-AB, early intraventricular polymyxin B plus continuous ventricular drainage could effectively clear the drug-resistant bacteria from CSF, thereby improving efficacy and reducing mortality. Renal functions before and after treatment were not changed significantly, proving that this combined treatment was safe and effective.

Candida central nervous system infection after neurosurgery: a single-institution case series and literature review.

BACKGROUND: Candida central nervous system (CNS) infection is a rare complication following neurosurgery. This disease often occurs during the treatment of bacterial CNS infection, and common bacterial culture results have a high false negative rate, which delays diagnosis and treatment, and seriously affect the prognosis of patients. The purpose of this study was to discuss the diagnosis, treatment process, and results of this disease through a small series of cases, so as to provide data support and a theoretical basis for the timely diagnosis and treatment of Candida CNS infection after neurosurgery. METHODS: A retrospective analysis was conducted on eight patients with confirmed Candida CNS infection following neurosurgery in our department between June 2011 and June 2019. Their clinical symptoms, treatment schemes, outcomes, risk factors, and complications were analyzed. RESULTS: Four patients received intravenous administration of fluconazole and were cured. Three patients received intravenous administration of amphotericin B. Two of them were cured, and the other died. One patient was cured after intravenous administration of voriconazole throughout the treatment. The overall cure rate was 87.5% (7/8), and the death rate was 12.5% (1/8). Among the three patients treated by amphotericin B, one patient suffered vomiting and renal function impairment. After drug discontinuation, this patient gradually improved. Another patient had acute renal failure, and the conditions were not improved after drug discontinuation. The remaining patient suffered from anemia and vomiting, which were relieved after drug discontinuation. One patient had hematuria during voriconazole treatment, and the symptoms were improved after the therapy was changed to fluconazole. Four patients treated with fluconazole did not have apparent adverse reactions. None of the cured patients relapsed during the 3-12 months follow-up after discharge. CONCLUSIONS: Candida CNS infection following neurosurgery is a rare condition; however, it may result in disastrous consequences. Early diagnosis and timely use of antifungal agents are considered the primary treatment principles. Blood culture of cerebrospinal fluid (CSF) is useful for early diagnosis. Fluconazole is the preferred choice for the clinical treatment of Candida CNS infection as it has both good efficacy and safety.

A Clinical Study on the Use of Intraventricular Polymyxin B Supplemented by Continuous External Ventricular Drainage in the Treatment of Drug-Resistant Gram-Negative Bacilli Intracranial Infection.

PURPOSE: To investigate the clinical effect of ventricular polymyxin B supplemented by continuous external ventricular drainage in the treatment of intracranial infection with multidrug-resistant (MDR) or extensively drug-resistant (XDR) Gram-negative (G-) bacilli following neurosurgery. PATIENTS AND METHODS: A retrospective analysis was performed on 28 patients who had G-bacilli intracranial infection following neurosurgery in our department between January 2017 and December 2019. The patients were treated with intraventricular polymyxin B supplemented by continuous external ventricular drainage. The clinical characteristics, treatment process, cerebrospinal-fluid-related indicators, results and prognosis were analysed. RESULTS: All of 28 patients developed an infection subsequent to neurosurgery, and cerebrospinal fluid (CSF) cultures demonstrated MDR/XDR G- bacilli, including Acinetobacter baumannii in 14 cases, Klebsiella pneumoniae in 9 cases, Pseudomonas aeruginosa in 3 cases, and Enterobacter cloacae in 2 cases. The ventricular drainage tube remained unobstructed in all patients during treatment, and intraventricular polymyxin B combined with intravenous antibiotics were administered each day. The duration of treatment with intraventricular polymyxin B was 14.96±4.28 days, and the time required to obtain a negative CSF culture was 8.23±4.02 days. The bacterial clearance rate from cerebrospinal fluid was 92.9% (26/28), and the clinical cure rate was 82.1% (23/28). Among them, 18 patients underwent ventriculoperitoneal shunt insertion for hydrocephalus 82.5 (59.5,114.75) days after the infection was cured, and the mortality rate was 17.6% (5/28). There was no significant change in patient blood creatinine levels before and after treatment. Cured patients were followed up for 4 months to 3 years, and no recurrences were observed. CONCLUSION: Treatment of intracranial infection with MDR/XDR G- bacilli using early intraventricular polymyxin B supplemented by continuous external ventricular drainage treatment may be a safe and effective treatment strategy.

Surgical Techniques and Long-Term Outcomes of Flexible Neuroendoscopic Aqueductoplasty and Stenting in Infants with Obstructive Hydrocephalus: A Single-Center Study.

OBJECTIVE: To technically review and explore long-term follow-up results of aqueductoplasty and stenting under flexible neuroendoscopy in infantile obstructive hydrocephalus. METHODS: The clinical data, surgical techniques, and long-term effects in 14 infants with obstructive hydrocephalus treated by flexible neuroendoscopic aqueductoplasty and stenting between 2008 and 2010 were analyzed retrospectively. RESULTS: The 14 infants had a mean age of 5.71 ± 3.10 months (range, 2-11 months) and a mean duration of follow-up of 62.64 ± 34.52 months (range, 9-121 months). Subdural effusion was observed in 4 infants (28.6%) after surgery. There were no deaths or serious complications related to intracranial stent placement. Three infants (21.4%) failed, 2 due to proximal aqueduct occlusion from a short stent length and 1 due to intraluminal ependymal adhesion obstruction. One case was abandoned when a second surgical adjustment stent was unsuccessful, and the other 2 cases went to shunt surgery. CONCLUSIONS: Aqueductoplasty with stenting is a feasible and safe surgical procedure for treating infants with midbrain aqueduct stenosis or occlusion. However, the optimal stent material and definitive outcomes after this procedure require additional long-term follow-up studies in large numbers of infants.