Reducing external ventricular drain associated ventriculitis: An improvement project in a level 1 trauma center.

BACKGROUND: External ventricular drain (EVD)-associated infections have a negative impact on healthcare cost and patient outcomes. Practice variation in EVD management may place patients at increased risk for EVD-associated infection. This project aimed to evaluate the impact of implementing an interprofessional evidence-based EVD bundle of care on reduction of EVD-related ventriculitis rates. METHODS: An interprofessional team developed an evidence based EVD care bundle and order set to eliminate practice inconsistencies. Standardization of EVD equipment and optimization of the electronic health record occurred. Education and competency validation were completed with neurosurgical providers and nurses. Interprofessional rounds occur weekly for observation, recognition, and in-the-moment education. RESULTS: A pre/post intervention design was used to show that the rate of EVD-associated ventriculitis decreased from 8.8 per reported EVD days in 2019 to 0 per reported EVD days in 2021 after implementation of the EVD care bundle. CONCLUSION: Through an interprofessional team approach, reduction in EVD-associated infection rates is feasible with implementation of an evidence based EVD care bundle.

Impact of an educational program on reducing health care-associated meningitis or ventriculitis in the neurosurgical intensive care unit.

BACKGROUND: Health care-associated meningitis or ventriculitis (HCAMV) is a serious complication in different neurosurgical procedures and is associated with significant morbidity and mortality. We aimed to investigate whether an educational intervention program could reduce the HCAMV incidence in patients undergoing postsurgery external ventricular drainage and wound management. METHODS: We enrolled 2,904 patients from the neurosurgery intensive care unit between January 1, 2016 and December 31, 2018. The medical staff undertook an educational program developed by a multidisciplinary team on correct external ventricular drainage insertion and maintenance. The program included a 9-page self-learning module on the HCAMV risk factors and operational improvements. Each participant completed a pre- and posttest on their HCAMV knowledge. RESULTS: We found that 38 of 693 (5.48%) patients presented with infection in the preintervention 9-month period. In the 27-month postintervention period, the proportion of HCAMV incidence dropped by 52.19% (P < .0001) to 58 of 2,211 (2.62%) patients. CONCLUSIONS: Educational intervention aimed at the neurosurgery intensive care unit staff could significantly reduce the HCAMV rate, leading to a significant decline in the cost, morbidity, and mortality caused by neurosurgical procedures.

Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance.

BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics. PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017. RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) and Clostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups. CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.

Decreasing External Ventricular Drain-Related Infection Rates with Duration-Independent, Clinically Indicated Criteria for Drain Revision: A Retrospective Study.

OBJECTIVE: To lower external ventricular drain (EVD)-related infection rates, in April 2013, our institution enacted a major protocol change, switching from routine EVD replacement every 5 days to EVD replacement only when clinically indicated. In the present study, we evaluated the effect of this change on nosocomial EVD-related infections. METHODS: We performed a retrospective cohort study to compare the EVD-related infection rates between 2 groups (group A, elective EVD replacement; group B, clinically indicated EVD replacement). We analyzed the data from 142 patients (group A, n = 43; group B, n = 99), with a total of 227 EVDs for 5 years and 3 months (1721 catheter days). RESULTS: The overall EVD-related infection rates were elevated in group A (0.14; 32% of patients) compared with group B (0.08; 8%; P = 0.001). The median hospital stay (33 vs. 24 days; P = 0.001) and neurosurgical intensive care unit stay (30.5 vs. 17 days; P < 0.0001) were also longer for group A. The requirement for multiple EVDs was an independent risk factor (P = 0.003), with a 4.6 times greater risk in group A (odds ratio, 4.64; 95% confidence interval, 1.7-12.6). CONCLUSIONS: The findings from our study strengthen an increasing body of evidence suggesting the importance of inoculation of skin flora as a critical risk factor for EVD-related infections, underscoring the importance of drain changes only when clinically indicated and that, as soon as clinically permitted, catheters should be removed.

An external ventricular drainage catheter impregnated with rifampicin, trimethoprim and triclosan, with extended activity against MDR Gram-negative bacteria: an in vitro and in vivo study.

BACKGROUND: External ventricular drainage (EVD) carries a high risk of ventriculitis, increasingly caused by MDR Gram-negative bacteria such as Escherichia coli and Acinetobacter baumannii. Existing antimicrobial EVD catheters are not effective against these, and we have developed a catheter with activity against MDR bacteria and demonstrated the safety of the new formulation for use in the brain. OBJECTIVES: Our aim was to determine the ability of a newly formulated impregnated EVD catheters to withstand challenge with MDR Gram-negative bacteria and to obtain information about its safety for use in the CNS. METHODS: Catheters impregnated with three antimicrobials (rifampicin, trimethoprim and triclosan) were challenged in flow conditions at four weekly timepoints with high doses of MDR bacteria, including MRSA and Acinetobacter, and monitored for bacterial colonization. Catheter segments were also inserted intracerebrally into Wistar rats, which were monitored for clinical and behavioural change, and weight loss. Brains were removed after either 1 week or 4 weeks, and examined for evidence of inflammation and toxicity. RESULTS: Control catheters colonized quickly after the first challenge, while no colonization occurred in the impregnated catheters even after the 4 week challenge. Animals receiving the antimicrobial segments behaved normally and gained weight as expected. Neurohistochemistry revealed only surgical trauma and no evidence of neurotoxicity. CONCLUSIONS: The antimicrobial catheter appears to withstand bacterial challenge for at least 4 weeks, suggesting that it might offer protection against infection with MDR Gram-negative bacteria in patients undergoing EVD. It also appears to be safe for use in the CNS.

Cerebrospinal fluid pharmacokinetics of ceftaroline in neurosurgical patients with an external ventricular drain.

BACKGROUND: Owing to its antibacterial properties, ceftaroline could be attractive for prevention or treatment of bacterial post-neurosurgical meningitis/ventriculitis. However, few data are available concerning its meningeal concentrations. OBJECTIVES: To investigate ceftaroline CSF pharmacokinetics in ICU patients with an external ventricular drain (EVD). METHODS: Patients received a single 600 mg dose of ceftaroline as a 1 h intravenous infusion. Blood and CSF samples were collected before and 0.5, 1, 3, 6, 12 and 24 h after the end of the infusion. Concentrations were assayed in plasma and CSF by LC-MS/MS. A two-step compartmental pharmacokinetic analysis was conducted. Ceftaroline plasma data were first analysed, and thereafter plasma parameters estimated and corrected for protein binding of 20% were fixed to fit unbound CSF concentrations. In the final model, parameters for both plasma and CSF data were simultaneously estimated. RESULTS: Nine patients with an EVD were included. The Cmax was 18.29 ± 3.33 mg/L in plasma (total concentrations) and at 0.22 ± 0.17 mg/L in CSF (unbound concentration). The model-estimated CSF input/CSF output clearance ratio was 9.4%, attesting to extensive efflux transport at the blood-CSF barrier. CONCLUSIONS: Ceftaroline CSF concentrations are too low to ensure prophylactic protection against most pathogens with MICs between 1 and 2 mg/L, owing to its limited central distribution.

The Role of Intraventricular Antibiotics in the Treatment of Nosocomial Ventriculitis/Meningitis from Gram-Negative Pathogens: A Systematic Review and Meta-Analysis.

BACKGROUND: The emergence of multidrug-resistant pathogens has resulted in difficult-to-treat ventriculitis/meningitis (VM). We used a meta-analysis to study the role of intraventricular (IVT) antibiotic administration as an adjunct (IVT plus intravenous [IV]) to the classic intravenous antimicrobial therapy (IV-only) in the management of VM in terms of infection control, functional outcome, microbial eradication, complications, cost-benefit analysis, infectious mortality, and overall mortality. METHODS: The electronic search focused on adult neurosurgical cases complicated by gram-negative VM and was limited to studies comparing IVT plus IV and IV-only. The quality of the overall body of evidence was assessed according to GRADE (Grading of Recommendations Assessment, Development, and Evaluation). The pooled estimates for each question were summarized as odds ratios (ORs) and visualized using forest plots. Every outcome was stratified according to carbapenem resistance. RESULTS: Eleven studies with 348 patients fulfilled the eligibility criteria. No evidence was found for infection control, functional outcome, or complications. For the remaining items evaluated, the overall quality of the best available evidence was low. IVT plus IV treatment was statistically superior to IV-only therapy in eradication (OR, 10.06; 95% confidence interval [CI], 2.62-38.65), infectious mortality (OR, 0.1; 95% CI, 0.03-0.36), and overall mortality (OR, 0.22; 95% CI, 0.08-0.60) in the management of carbapenem-resistant pathogens only. CONCLUSIONS: Combined IVT plus IV treatment did not prove superior to standard IV-only treatment in the management of VM. Nevertheless, weak evidence showed that IVT treatment might serve as an adjunct in the management of carbapenem-resistant pathogens.

Silver-Coated Ventriculostomy Catheters Do Not Reduce Rates of Clinically Diagnosed Ventriculitis.

BACKGROUND: Ventriculitis is a serious complication when using external ventricular drains (EVDs). Bactericidal silver coating has been reported to reduce risk of infection. In the clinical setting, the diagnosis is often made based on symptoms and analyses of cerebrospinal fluid, with treatment initiated before infection is verified by culture. The bactericidal effect might not correlate with a reduced rate of clinically diagnosed infections. This retrospective study aimed to analyze if use of silver-coated EVDs is associated with a reduced rate of ventriculitis. METHODS: During 1 year, clinical routine was changed from inserting noncoated catheters to silver-coated catheters. Rate of ventriculitis was compared between patient groups based on catheter type. To examine the clinical impact of silver coating, ventriculitis was defined as cases where antibiotic treatment was initiated on clinical suspicion. RESULTS: Among 296 patients (186 noncoated and 110 silver-coated catheters), 18.9% were treated for ventriculitis, with 21.0% in the noncoated group and 15.5% in the silver-coated group (P = 0.242). Silver coating did not reduce the rate of positive cultures. Duration of EVD treatment was the single significant risk factor for ventriculitis. Silver-coated catheters did not reduce the need for cerebrospinal fluid shunt placement, days with antibiotics, days with EVD, or days in the intensive care unit. CONCLUSIONS: The previously reported bactericidal effect of silver-coated EVDs did not alter the clinical course to significantly reduce the number of treated cases of ventriculitis. The introduction of silver-coated EVDs cannot be motivated by reduced use of antibiotics or shorter hospital stay.

A Simple Infection Control Protocol Durably Reduces External Ventricular Drain Infections to Near-Zero Levels.

OBJECTIVE: External ventricular drains (EVDs) historically have a high rate of infection, and EVD infections are a cause of significant morbidity and mortality. We have shown previously that a simple infection control protocol reduced the rate of EVD infections during a 3-year period, and the present study examines whether infection rates were durably reduced over an additional 4 years. METHODS: Retrospective analysis of EVDs placed in the intensive care unit of a tertiary neurosurgical center over an additional 4 year follow-up period. RESULTS: In the 4-year follow-up period, 189 EVDs were placed in 173 patients. The previously observed decrease in cerebrospinal fluid culture positivity from 9.8% in the baseline period to 0.8% in the first 3 years of the protocol period continued in the 4-year follow-up period (0%, 0 of 189 EVD placements, 0 per 1000 catheter-days; P < 0.001 compared with baseline). The previously observed decrease in the rate of ventriculitis from 6.3% to 0.8% also continued in the follow-up period (0%, 0 of 189 EVD placements, 0 per 1000 catheter-days; P < 0.001 compared with baseline). Over the total 7 years of protocol use, the rate of culture positivity was 0.3% (1 of 308 EVD placements, 0.29 per 1000 catheter-days) and the rate of ventriculitis was 0.3% (1 of 308 EVD placements, 0.29 per 1000 catheter-days). The only observed infection over 7 years occurred in a patient who removed their own EVD. CONCLUSIONS: A straightforward EVD infection control protocol substantially and durably reduces EVD infections to a near-zero rate.

Reducing external drainage-related cerebrospinal fluid infections through implementation of a multidisciplinary protocol: experience in a paediatric hospital.

OBJECTIVE: To assess the frequency of external cerebrospinal fluid (CSF) drain-related CNS infections before and after implementation of a protocol for their prevention. DESIGN: Quasi-experimental study, with comparison of incidence before and after the implementation of the intervention. SETTING AND PARTICIPANTS: Bambino Gesù Children's Hospital in Rome, Italy. Children receiving an external cerebrospinal fluid drain from 1 January 2013 to 31 March 2015. MAIN OUTCOME MEASURES: Drain-related infections. RESULTS: Fifty-two patients were included in the study. Before protocol implementation, cumulative incidence was 14 per 100 drains. Incidence rate was 8/1,000 catheter-days. After protocol implementation, cumulative incidence and incidence rate were 6.7 per 100 drains and 4.6 per 1,000 catheter-days (p=0.61 and p=0.2 versus the pre-intervention period, respectively). Infected patients were significantly younger (median age: 16.5 days vs 13.4 months; p=0.026), had a significantly higher number of procedures (5 vs 1 procedure per patient; p <0.0001) and were most frequently affected by post-haemorrhagic hydrocephalus of premature newborns (50% vs 16.7%; p=0.039), compared to non-infected patients. CONCLUSIONS: After protocol implementation, we observed a reduction of incidence of CSF drain-related infections, though the short post-intervention period limited the power of the study to detect a significant difference. Patients <1 year of age, with multiple interventions and post-haemorrhagic hydrocephalus had higher risk of CSF drain-related infections.

No additional protection against ventriculitis with prolonged systemic antibiotic prophylaxis for patients treated with antibiotic-coated external ventricular drains.

OBJECT External ventricular drains (EVDs) are commonly used for CSF diversion but pose a risk of ventriculitis, with rates varying in frequency from 2% to 45%. Results of studies examining the utility of prolonged systemic antibiotic therapy for the prevention of EVD-related infection have been contradictory, and no study to date has examined whether this approach confers additional benefit in preventing ventriculitis when used in conjunction with antibiotic-coated EVDs (ac-EVDs). METHODS A prospective performance analysis was conducted over 4 years to examine the impact of discontinuing systemic antibiotic prophylaxis after insertion of an ac-EVD on rates of catheter-related ventriculitis. Ventriculitis and other nosocomial infections were ascertained by a qualified infection disease nurse using definitions based on published standards from the Centers for Disease Control and Prevention, comparing the period when patients received systemic antibiotic therapy for the duration of EVD treatment (Period 1) compared with only for the peri-insertion period (Period 2). Costs were analyzed and compared across the 2 time periods. RESULTS Over the 4-year study period, 866 patients were treated with ac-EVDs for a total of 7016 catheter days. There were 8 cases of ventriculitis, for an overall incidence of 0.92%. Rates of ventriculitis did not differ significantly between Period 1 and Period 2 (1.1% vs 0.4%, p = 0.22). The rate of nosocomial infections, however, was significantly higher in Period 1 (2.0% vs 0.0% in Period 2, p = 0.026). Cost savings of $162,516 were realized in Period 2 due to decreased drug costs and savings associated with the reduction in nosocomial infections. CONCLUSIONS Prolonged systemic antibiotic therapy following placement of ac-EVDs does not seem to reduce the incidence of catheter-related ventriculitis and was associated with a higher rate of nosocomial infections and increased cost.

Surveillance and management of ventriculitis following neurosurgery.

Ventriculitis is an important complication following neurosurgery and is often associated with the use of an external ventricular drain (EVD). The incidence varies from <5% to 20%, partly due to variations in the definitions used for diagnosis. Staphylococci are the most important causes but the isolation of coagulase-negative staphylococci from a cerebrospinal fluid (CSF) sample needs to be interpreted with caution as it may represent contamination. Risk factors for ventriculitis include advanced age, the duration of EVD placement, the number of manipulations and the presence of intraventricular haemorrhage. Prevention strategies increasingly focus on the implementation of a care bundle that includes aseptic technique at the time of insertion and during any manipulations, skin preparation, prophylactic antibiotics, and appropriate dressings at the site of the EVD. The use of EVDs impregnated with antimicrobial agents is increasing but, whereas some studies show that these are effective, it is not clear whether they provide added benefit when there is compliance with other measures. Antimicrobial treatment is challenging as many widely used agents do not penetrate into the CSF and causative bacteria are increasingly multidrug resistant. Often a combination of high-dose intravenous and intraventricular agents is required, especially for Gram-negative infections. Large trials in this area are challenging to conduct; therefore, to better inform preventive strategies and to optimize management of this important condition, ongoing national surveillance and pooling of data on treatment approaches and outcomes are needed.

Ventriculostomy Infections at the Paediatric Neurosurgical Unit at Dr George Mukhari Academic Hospital

Background. External ventricular drains (EVDs) are essential to the clinical management and care of patients with neurosurgical complications; but EVD use is routinely associated with concomitant infection; sometimes resulting in mortality. Objective. To undertake an epidemiological study of ventriculostomy-related infections among paediatric neurosurgical patients at the Dr George Mukhari Academic Hospital; Pretoria; South Africa. Methods. Retrospective analysis was conducted on the clinical records of 92 children admitted to the neurosurgical unit at the hospital between 2010 and 2013. Records were included in the study only if they were complete; legible and accurate. Data were collected on the following variables: age; gender; frequency of catheter change; cerebrospinal fluid (CSF) sampling; use of prophylaxis; microbiology; Glasgow Coma Scale; glucose; chlorine; and other clinical; chemical and laboratory parameters routinely observed as part of patients' work-ups. Results. Two or more EVDs were placed on 45.7 (40) children; with a maximum of seven EVDs per child. Ventriculitis incidence was 28.3 (26 of 92). There was a significant association between the number of EVDs inserted and the incidence of ventriculitis (p=0.010). More frequent CSF sampling also increased ventricular-related infections (p=0.000); as did prolonged EVD retention (p=0.001). Using prophylactic antibiotics or impregnated catheters did not reduce ventriculitis incidence significantly. Conclusion. Evidence supports adherence to strict sterilisation protocols and techniques when inserting EVDs. Catheters should not be retained for extended periods; and CSF sampling can be limited to once in 3 days. Routine use of antibiotic-impregnated EVDs and antistaphylococcal prophylaxis is still recommended

Use of a cyanoacrylate skin adhesive to reduce external ventricular drain infection rates.

UNLABELLED: OBJECT.: Ventriculitis related to external ventricular drain (EVD) placement is a significant source of morbidity in neurological intensive care patients. Current rates of EVD-related infections range from 2% to 45% in the literature. The authors sought to determine if a 2-octyl cyanoacrylate adhesive would result in lower infection rate than standard semiocclusive dressings. METHODS: The authors tracked ventriculitis rates via CSF cultures among 259 patients whose EVD sites were dressed with sterile semiocclusive dressings and underwent routine sterile dressing exchanges every 48 hours. They analyzed data obtained in an additional 113 patients whose EVD sites were dressed one time with a surgical adhesive, 2-octyl cyanoacrylate. RESULTS: Ventriculitis rate in patients with standard bioocclusive dressings and wound care was 15.1%, whereas that in patients with a 2-octyl cyanoacrylate dressing was 3.54% (p = 0.002). Staphylococcus genus accounted for 79.5% of instances of ventriculitis among patients with bioocclusive dressings and routine wound care, whereas it accounted for 25.0% of the instances of ventriculitis among patients with a liquid polymer sealant dressing. A 90% reduction in Staphylococcus infection completely accounts for the observed effect (p = 0.04). CONCLUSIONS: The one-time application of 2-octyl cyanoacrylate to EVD wounds and exit sites provided superior protection against EVD-related ventriculitis compared to conventional EVD-site wound care. Likely this protection results from a barrier to the entry of gram-positive skin flora along the EVD exit tract. The results should be validated in a randomized trial.

Bundle of measures for external cerebral ventricular drainage-associated ventriculitis.

OBJECTIVE: To assess the prevalence and outcome of external cerebral ventricular drainage-associated ventriculitis in neurocritical patients before and after the implementation of a bundle of external cerebral ventricular drainage-associated ventriculitis control measures. DESIGN: Clinical prospective case series. SETTING: University Hospital of Larissa, Greece. PATIENTS: Consecutive patients were recruited from the ICU of the hospital. Patient inclusion criteria included presence of external ventricular drainage and ICU stay more than 48 hours. INTERVENTION: The bundle of external cerebral ventricular drainage-associated ventriculitis control measures included 1) reeducation of ICU personnel on issues of infection control related to external cerebral ventricular drainage, 2) meticulous intraventricular catheter handling, 3) cerebrospinal fluid sampling only when clinically necessary, and 4) routine replacement of the drainage catheter on the seventh drainage day if the catheter was still necessary. The bundle was applied after an initial period (preintervention) where standard policy for external cerebral ventricular drainage-associated ventriculitis was established. MEASUREMENTS: External cerebral ventricular drainage-associated ventriculitis prevalence, external cerebral ventricular drainage-associated ventriculitis events per 1,000 drainage days (drain-associated infection rate), length of ICU stay, Glasgow Outcome Scale at 6 months, and risk factors for external cerebral ventricular drainage-associated ventriculitis. MAIN RESULTS: Eighty-two patients entered the study in the preintervention period and 57 patients during the intervention period. During the preintervention and intervention period, external cerebral ventricular drainage-associated ventriculitis prevalence was 28% and 10.5% (p = 0.02) and drain-associated infection rate was 18 and 7.1, respectively (p = 0.0001); mean (95% CI) length of ICU stay in patients who presented external cerebral ventricular drainage-associated ventriculitis was 44.4 days (36.4-52.4 d), whereas mean (95% CI) length of ICU stay in patients who did not was 20 days (16.9-23.2 d) (p < 0.001). Furthermore, the length of ICU stay was associated with length of drainage (p = 0.0001). Therefore, the presence of external cerebral ventricular drainage-associated ventriculitis and the length of drainage were the only variables associated with a prolonged ICU stay. Unfavorable outcome in Glasgow Outcome Scale at 6 months was not associated with the presence of external cerebral ventricular drainage-associated ventriculitis (p = 0.5). No significant differences were found when Glasgow Outcome Scale was analyzed according to the two study periods. CONCLUSIONS: The implementation of a bundle of measures for external cerebral ventricular drainage-associated ventriculitis control was associated with significantly decreased postintervention prevalence of the infection.