Ventriculitis

Question 1

Ventriculitis
Q. Definition
Q. Etiology

Answer 1

=> Definition: Inflammation of the ventricular system, usually bacterial in origin

=> Etiology:
* Primary: Direct infection (e.g., from CSF breach)
* Secondary: Following meningitis, abscess, inflammation, necrosis, or shunt/EVD

Complicates 30%cases of Meningitis in adults and 90% in Neonates

Question 2

EVD-Related Ventriculitis
Q. Risk factors for EVD related ventriculitis
Q. Common Organisms

Answer 2

🔹 Risk Factors:
* Poor insertion technique
* Long EVD dwell time
* Frequent sampling
* Multiple catheter insertions/changes
* CSF leak
* Previous infections

🔹 Common Organisms:
* Gram-positive cocci: Staph aureus, Staph epidermidis
* GNB (esp. in VP shunts): e.g., E. coli, Klebsiella(peritoneal contamination)
* Fungi: Consider in immunosuppressed patients

Question 2

Clinical features of Ventriculitis

Answer 2

Clinical Features
* Headache, nausea, vomiting
* Altered mental status, seizures
* Fever
* New focal deficits
* Raised ICP
* Secondary Hydrocephalus
* Seizures
* Tenderness around site of EVD insertion
* Worsening vasopressor req.

Question 2

Investigations

Answer 2

🔸 Labs:
* FBC, CRP, procalcitonin
* Septic screen: blood, urine, sputum

🔸 CSF Analysis:
* ↑ WBC/RBC, ↓ glucose, ↑ protein
* CSF:serum glucose ratio < 0.4
* Cell index (CSF leukocytes/RBCs)->
Normal-1:500;
Very suggestive-1:100 / Increasing trend
* Culture + microscopy
* NAAT, fungal panels, beta D glucan if immunosuppressed

🔸 Imaging:
* CT/MRI:
- Periventricular hyperintensity
- Ventricular debris, enhancement, hydrocephalus

Question 3

❗ Diagnostic Challenges

Answer 3

=> Inflammatory changes from TBI or EVD can
i). Mimic ventriculitis (fever, leukocytosis, altered CSF)/ mask features of infection

ii). Confound interpretation of imaging or CSF

=> Blood in ventricles can alter CSF parameters (↑ protein, RBCs)

=> CSF findings may overlap with aseptic inflammation

=>Clinical signs eg- drop in GCS Difficult to appreciate in early stages or in sedated/ventilated patients

=>No universally accepted definition of Ventriculitis

=>Fever common due to presence of blood in ventricles

Question 4

Treatment Principles

Answer 4

=>Empiric Antibiotics: Broad spectrum with good CNS penetration, Gram Negative and MRSA cover.
=> Start immediately if suspected
- Vancomycin 25 mg/kg IV Bolus foll by infusion with TDM or 20mg/kg bd with TDM
- Meropenem 2 g IV TDS (or cefepime/ceftazidime)
* Tailor to culture/sensitivities

EVD Management:
* Replace or remove infected EVD
* Consider intraventricular antibiotics for MDR organisms

Duration:
* Minimum 3 weeks
* Continue ≥4 days after negative cultures