Neurosurgical Infections

Abstract

Patients in the neurointensive care unit often undergo life-saving neurosurgical interventions that can be associated with serious complications. Infection is a common and sometimes fatal complication of such procedures. Infection may occur not only in the setting of major cranial and spinal surgery, but also with common minor procedures that utilize neurosurgical devices, such as placement of external ventricular drains, ventriculoperitoneal shunts, and deep brain stimulators. In this article, we review the epidemiology and microbiology of these infections, and discuss their general and procedure-specific risk factors and treatment options.

Keywords

neurosurgical infection - external ventricular drain - shunt - craniotomy - iatrogenic infection

• References

• 1 O'Horo JC, Sampathkumar P. Infections in neurocritical care. Neurocrit Care 2017; 27 (03) 458-467
• 2 Ramanan M, Lipman J, Shorr A, Shankar A. A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis 2015; 15: 3
• 3 Girgis F, Walcott BP, Kwon CS. , et al. The absence of fever or leukocytosis does not exclude infection following cranioplasty. Can J Neurol Sci 2015; 42 (04) 255-259
• 4 van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med 2010; 362 (02) 146-154
• 5 Berger C, Schwarz S, Schaebitz WR, Aschoff A, Schwab S. Serum procalcitonin in cerebral ventriculitis. Crit Care Med 2002; 30 (08) 1778-1781
• 6 Martínez R, Gaul C, Buchfelder M, Erbguth F, Tschaikowsky K. Serum procalcitonin monitoring for differential diagnosis of ventriculitis in adult intensive care patients. Intensive Care Med 2002; 28 (02) 208-210
• 7 Fam MD, Zeineddine HA, Eliyas JK. , et al; CLEAR III Trial Investigators. CSF inflammatory response after intraventricular hemorrhage. Neurology 2017; 89 (15) 1553-1560
• 8 Polage CR, Cohen SH. State-of-the-art microbiologic testing for community-acquired meningitis and encephalitis. J Clin Microbiol 2016; 54 (05) 1197-1202
• 9 Zarrouk V, Vassor I, Bert F. , et al. Evaluation of the management of postoperative aseptic meningitis. Clin Infect Dis 2007; 44 (12) 1555-1559
• 10 Schade RP, Schinkel J, Roelandse FWC. , et al. Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. J Neurosurg 2006; 104 (01) 101-108
• 11 Walti LN, Conen A, Coward J, Jost GF, Trampuz A. Characteristics of infections associated with external ventricular drains of cerebrospinal fluid. J Infect 2013; 66 (05) 424-431
• 12 Meredith FT, Phillips HK, Reller LB. Clinical utility of broth cultures of cerebrospinal fluid from patients at risk for shunt infections. J Clin Microbiol 1997; 35 (12) 3109-3111
• 13 Lindquist L, Linné T, Hansson LO, Kalin M, Axelsson G. Value of cerebrospinal fluid analysis in the differential diagnosis of meningitis: a study in 710 patients with suspected central nervous system infection. Eur J Clin Microbiol Infect Dis 1988; 7 (03) 374-380
• 14 Huy NT, Thao NTH, Diep DTN, Kikuchi M, Zamora J, Hirayama K. Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis. Crit Care 2010; 14 (06) R240
• 15 Jamjoom AAB, Joannides AJ, Poon MTC. , et al; British Neurosurgical Trainee Research Collaborative. Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland. J Neurol Neurosurg Psychiatry 2018; 89 (02) 120-126
• 16 Seidelman J, Lewis SS. Neurosurgical device-related infections. Infect Dis Clin North Am 2018; 32 (04) 861-876
• 17 Martin RM, Zimmermann LL, Huynh M, Polage CR. Diagnostic approach to health care- and device-associated central nervous system infections. J Clin Microbiol 2018; 56 (11) e00861-18
• 18 Grill MF, Maganti RK. Neurotoxic effects associated with antibiotic use: management considerations. Br J Clin Pharmacol 2011; 72 (03) 381-393
• 19 Shapiro S, Boaz J, Kleiman M, Kalsbeck J, Mealey J. Origin of organisms infecting ventricular shunts. Neurosurgery 1988; 22 (05) 868-872
• 20 Kanev PM, Sheehan JM. Reflections on shunt infection. Pediatr Neurosurg 2003; 39 (06) 285-290
• 21 Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 2001; 94 (02) 195-201
• 22 Vinchon M, Dhellemmes P. Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 2006; 22 (07) 692-697
• 23 Simon TD, Butler J, Whitlock KB. , et al; Hydrocephalus Clinical Research Network. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 2014; 164 (06) 1462-8.e2
• 24 Borgbjerg BM, Gjerris F, Albeck MJ, Børgesen SE. Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir (Wien) 1995; 136 (1-2): 1-7
• 25 McGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 2003; 36 (07) 858-862
• 26 Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis 2008; 47 (01) 73-82
• 27 Wang KW, Chang WN, Shih TY. , et al. Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis 2004; 57 (02) 44-48
• 28 Tunkel AR, Hasbun R, Bhimraj A. , et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017 2017. Doi: 10.1093/cid/ciw861
• 29 Pelegrín I, Lora-Tamayo J, Gómez-Junyent J. , et al. Management of ventriculoperitoneal shunt infections in adults: analysis of risk factors associated with treatment failure. In: Clinical Infectious Diseases; 2017. Doi: 10.1093/cid/cix005
• 30 Wen DY, Bottini AG, Hall WA, Haines SJ. Infections in neurologic surgery. The intraventricular use of antibiotics. Neurosurg Clin N Am 1992; 3 (02) 343-354
• 31 James HE, Walsh JW, Wilson HD, Connor JD, Bean JR, Tibbs PA. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 1980; 7 (05) 459-463
• 32 Leverstein-van Hall MA, Hopmans TEM, van der Sprenkel JWB. , et al. A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. J Neurosurg 2010; 112 (02) 345-353
• 33 Lozier AP, Sciacca RR, Romagnoli MF, Connolly Jr ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2002; 51 (01) 170-181 , discussion 181–182
• 34 Sieg EP, Schlauderaff AC, Payne RA, Glantz MJ, Simon SD. Impact of an external ventricular drain placement and handling protocol on infection rates: a meta-analysis and single institution experience. World Neurosurg 2018; 115: e53-e58
• 35 Korinek AM. ; Service Epidémiologie Hygiène et Prévention. Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients. The French Study Group of Neurosurgical Infections, the SEHP, and the C-CLIN Paris-Nord. Neurosurgery 1997; 41 (05) 1073-1079 , discussion 1079–108
• 36 Korinek AM, Golmard JL, Elcheick A. , et al. Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg 2005; 19 (02) 155-162
• 37 Odio C, McCracken Jr GH, Nelson JD. CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 1984; 138 (12) 1103-1108
• 38 Lyke KE, Obasanjo OO, Williams MA, O'Brien M, Chotani R, Perl TM. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis 2001; 33 (12) 2028-2033
• 39 Nilsson A, Uvelius E, Cederberg D, Kronvall E. Silver-coated ventriculostomy catheters do not reduce rates of clinically diagnosed ventriculitis. World Neurosurg 2018; 117: e411-e416
• 40 Holloway KL, Barnes T, Choi S. , et al. Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients. J Neurosurg 1996; 85 (03) 419-424
• 41 Wong GKC, Poon WS, Wai S, Yu LM, Lyon D, Lam JMK. Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2002; 73 (06) 759-761
• 42 Beer R, Lackner P, Pfausler B, Schmutzhard E. Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 2008; 255 (11) 1617-1624
• 43 Youmans J, Winn H. Youmans Neurological Surgery; 2011 Doi: 10.1016/B978-1-4160-5316-3.00020-4
• 44 Morton R, Lucas II TH, Ko A, Browd SR, Ellenbogen RG, Chesnut RM. Intracerebral abscess associated with the Camino intracranial pressure monitor: case report and review of the literature. Neurosurgery 2012; 71 (01) E193-E198
• 45 Sonabend AM, Korenfeld Y, Crisman C, Badjatia N, Mayer SA, Connolly Jr ES. Prevention of ventriculostomy-related infections with prophylactic antibiotics and antibiotic-coated external ventricular drains: a systematic review. Neurosurgery 2011; 68 (04) 996-1005
• 46 Haines SJ, Walters BC. Antibiotic prophylaxis for cerebrospinal fluid shunts: a metanalysis. Neurosurgery 1994; 34 (01) 87-92
• 47 Langley JM, LeBlanc JC, Drake J, Milner R. Efficacy of antimicrobial prophylaxis in placement of cerebrospinal fluid shunts: meta-analysis. Clin Infect Dis 1993; 17 (01) 98-103
• 48 Dawod J, Tager A, Darouiche RO, Al Mohajer M. Prevention and management of internal cerebrospinal fluid shunt infections. J Hosp Infect 2016; 93 (04) 323-328
• 49 Eymann R, Chehab S, Strowitzki M, Steudel W-I, Kiefer M. Clinical and economic consequences of antibiotic-impregnated cerebrospinal fluid shunt catheters. J Neurosurg Pediatr 2008; 1 (06) 444-450
• 50 Humphreys H, Jenks PJ. Surveillance and management of ventriculitis following neurosurgery. J Hosp Infect 2015; 89 (04) 281-286
• 51 Edwards NC, Engelhart L, Casamento EMH, McGirt MJ. Cost-consequence analysis of antibiotic-impregnated shunts and external ventricular drains in hydrocephalus. J Neurosurg 2015; 122 (01) 139-147
• 52 Zabramski JM, Whiting D, Darouiche RO. , et al. Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial. J Neurosurg 2003; 98 (04) 725-730
• 53 Root BK, Barrena BG, Mackenzie TA, Bauer DF. Antibiotic impregnated external ventricular drains: meta and cost analysis. World Neurosurg 2016; 86: 306-315
• 54 Atkinson RA, Fikrey L, Vail A, Patel HC. Silver-impregnated external-ventricular-drain-related cerebrospinal fluid infections: a meta-analysis. J Hosp Infect 2016; 92 (03) 263-272
• 55 Parker S, Murphy J, Engelhart L, McGirt M. Comparative effectiveness and cost-benefit analysis of antibiotic-impregnated shunt catheters in the treatment of hydrocephalus: analysis of 12,589 consecutive cases from 287 hospital systems. J Neurosurg 2013 Doi: 10.3171/2014.4.JNS14689.submitted
• 56 Pople I, Poon W, Assaker R. , et al. Comparison of infection rate with the use of antibiotic-impregnated vs standard extraventricular drainage devices: a prospective, randomized controlled trial. Neurosurgery 2012; 71 (01) 6-13
• 57 Bookland MJ, Sukul V, Connolly PJ. Use of a cyanoacrylate skin adhesive to reduce external ventricular drain infection rates. J Neurosurg 2014; 121 (01) 189-194
• 58 O'Keeffe AB, Lawrence T, Bojanic S. Oxford craniotomy infections database: a cost analysis of craniotomy infection. Br J Neurosurg 2012; 26 (02) 265-269
• 59 Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Galacho-Harriero AM, Rodríguez-Salazar A. Preservation of bone flap after craniotomy infection. Neurocirugia (Astur) 2009; 20 (02) 124-131
• 60 Malcolm JG, Rindler RS, Chu JK, Grossberg JA, Pradilla G, Ahmad FU. Complications following cranioplasty and relationship to timing: a systematic review and meta-analysis. J Clin Neurosci 2016; 33: 39-51
• 61 Bhatti MI, Leach PA. The incidence of infection for adults undergoing supra-tentorial craniotomy for tumours without hair removal. Br J Neurosurg 2013; 27 (02) 218-220
• 62 Kinaci A, Algra A, Heuts S, O'Donnell D, van der Zwan A, van Doormaal T. Effectiveness of dural sealants in prevention of cerebrospinal fluid leakage after craniotomy: a systematic review. World Neurosurg 2018; 118: 368-376.e1
• 63 Mustroph CM, Malcolm JG, Rindler RS. , et al. Cranioplasty infection and resorption are associated with the presence of a ventriculoperitoneal shunt: a systematic review and meta-analysis. World Neurosurg 2017; 103: 686-693
• 64 Cheah PP, Rosman AK, Cheang CK, Idris B. Autologous cranioplasty post-operative surgical site infection: does it matter if the bone flaps were stored and handled differently?. Malays J Med Sci 2017; 24 (06) 68-74
• 65 Inamasu J, Kuramae T, Nakatsukasa M. Does difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservation. J Trauma 2010; 68 (01) 183-187 , discussion 187
• 66 Ho AL, Cannon JGD, Mohole J. , et al. Topical vancomycin surgical prophylaxis in pediatric open craniotomies: an institutional experience. J Neurosurg Pediatr 2018; 22 (06) 710-715
• 67 Ravikumar V, Ho AL, Pendhakar AV, Sussman ES, Kwong-Hon Chow K, Li G. The use of vancomycin powder for surgical prophylaxis following craniotomy. Neurosurgery 2017; 80 (05) 754-758
• 68 Mallela AN, Abdullah KG, Brandon C, Richardson AG, Lucas TH. Topical vancomycin reduces surgical-site infections after craniotomy: a prospective, controlled study. Neurosurgery 2018; 83 (04) 761-767
• 69 Nota SPFT, Braun Y, Ring D, Schwab JH. Incidence of surgical site infection after spine surgery: what is the impact of the definition of infection?. Clin Orthop Relat Res 2015; 473 (05) 1612-1619
• 70 Ferry T, Valour F, Lustig S. , et al. The challenge of infection prevention in spine surgery: an update. Eur J Orthop Surg Traumatol 2013; 23 (Suppl. 01) S15-S19
• 71 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (05) 373-383
• 72 Cizik AM, Lee MJ, Martin BI. , et al. Using the spine surgical invasiveness index to identify risk of surgical site infection: a multivariate analysis. J Bone Joint Surg Am 2012; 94 (04) 335-342
• 73 Fang A, Hu SS, Endres N, Bradford DS. Risk factors for infection after spinal surgery. Spine 2005; 30 (12) 1460-1465
• 74 Boody BS, Tarazona DA, Vaccaro AR. Evaluation and management of pyogenic and tubercular spine infections. Curr Rev Musculoskelet Med 2018; 11 (04) 643-652
• 75 Dobran M, Marini A, Gladi M. , et al. Deep spinal infection in instrumented spinal surgery: diagnostic factors and therapy. G Chir 2017; 38 (03) 124-129
• 76 Stenehjem E, Armstrong WS. , et al. Central nervous system device infections. Infect Dis Clin North Am 2012; 26 (01) 89-110
• 77 Fily F, Haegelen C, Tattevin P. , et al. Deep brain stimulation hardware-related infections: a report of 12 cases and review of the literature. Clin Infect Dis 2011; 52 (08) 1020-1023
• 78 Gorgulho A, Juillard C, Uslan DZ. , et al. Infection following deep brain stimulator implantation performed in the conventional versus magnetic resonance imaging-equipped operating room. J Neurosurg 2009; 110 (02) 239-246
• 79 Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience. Neurosurgery 2006; 58 (03) 481-496 , discussion 481–496
• 80 Follett KA, Boortz-Marx RL, Drake JM. , et al. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology 2004; 100 (06) 1582-1594
• 81 Ghosh D, Mainali G, Khera J, Luciano M. Complications of intrathecal baclofen pumps in children: experience from a tertiary care center. Pediatr Neurosurg 2013; 49 (03) 138-144