====== Post-neurosurgical meningitis treatment ====== see also [[Meningitis treatment]] {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1hCS5QvDf5qXRk1ln4puFUZk15ZnqyEDP8zP4XzCcr9FVndEdX/?limit=15&utm_campaign=pubmed-2&fc=20231005062046}} ### **Treatment of Post-Neurosurgical Meningitis** Post-neurosurgical meningitis (PNM) is a severe complication that often results from breaches in the blood-brain barrier due to surgery, trauma, or cerebrospinal fluid (CSF) leaks. Treatment requires prompt initiation of targeted antimicrobial therapy based on suspected or identified pathogens. Here’s a general approach: --- ### **1. Empirical Antimicrobial Therapy** Empirical therapy is initiated immediately, tailored to cover common pathogens, until microbiological results (e.g., CSF cultures) are available. - **Pathogens to Cover**: - Gram-positive bacteria: *Staphylococcus aureus* (including MRSA), coagulase-negative staphylococci (*e.g., S. epidermidis*), *Streptococcus pneumoniae*. - Gram-negative bacteria: *Pseudomonas aeruginosa*, *Klebsiella spp.*, *Escherichia coli*. - **First-Line Empirical Therapy**: - **Vancomycin**: Targets Gram-positive organisms, especially MRSA and coagulase-negative staphylococci. - **Cefepime** or **Meropenem**: Broad-spectrum antibiotics effective against Gram-negative pathogens, including *Pseudomonas*. Alternatively: - **Linezolid**: May be considered if vancomycin is contraindicated. - **Ceftazidime** or **Aztreonam**: Options for patients with penicillin allergy, focused on Gram-negative coverage. --- ### **2. Pathogen-Specific Therapy** Once the causative organism is identified, therapy should be narrowed to improve efficacy and reduce resistance risks. - **Staphylococcus aureus**: - Methicillin-sensitive: **Nafcillin** or **Cefazolin**. - Methicillin-resistant (MRSA): **Vancomycin** or **Daptomycin**. - **Coagulase-negative staphylococci**: - Vancomycin or **Rifampin** (added in prosthetic-related infections). - **Gram-negative bacteria** (*e.g., Pseudomonas aeruginosa*): - **Cefepime**, **Meropenem**, or **Piperacillin-tazobactam**. - Combination therapy with **Amikacin** or **Ciprofloxacin** may be used in severe cases. - **Polymicrobial infections**: - Broad-spectrum agents such as **Meropenem** or **Piperacillin-tazobactam**, with adjustments based on culture results. --- ### **3. Route and Duration of Therapy** - **Route**: - Begin with intravenous (IV) antibiotics to achieve rapid therapeutic CSF levels. - Switch to oral antibiotics if effective options are available, the patient is clinically stable, and the pathogen is susceptible. - **Duration**: - Typically 10–21 days, depending on the severity of infection, causative organism, and clinical response. --- ### **4. Adjunctive Measures** - **CSF Drainage**: If a CSF leak, abscess, or hydrocephalus is present, surgical intervention (e.g., external ventricular drainage, craniotomy) is often necessary. - **Remove/Replace Infected Devices**: External or internal shunts, catheters, or prosthetics implicated in infection must be addressed. --- ### **5. Special Considerations** - **Biofilm Formation**: Infections involving implants or hardware often involve biofilm-producing pathogens, requiring prolonged treatment and sometimes rifampin for its anti-biofilm activity. - **Intrathecal Antibiotics**: Considered in refractory cases or when IV antibiotics fail to penetrate CSF adequately. --- ### **6. Monitor and Adjust** - Regular monitoring of: - Clinical symptoms: Fever, neurological deficits. - CSF parameters: Cell count, glucose, protein, culture results. - Drug levels (e.g., vancomycin troughs) to ensure therapeutic efficacy. ### **7. Prevention** - Preoperative prophylaxis with cefazolin or vancomycin. - Strict aseptic techniques during surgery. - Early repair of CSF leaks. --- ### Example Regimen for Post-Neurosurgical Meningitis 1. **Empirical Therapy**: - Vancomycin + Cefepime or Meropenem. 2. **Pathogen-Specific Adjustments**: - Switch based on culture (e.g., MSSA: Nafcillin, Gram-negative: Cefepime). 3. **Duration**: - 14–21 days total, including transition to oral therapy if appropriate. Close multidisciplinary coordination between neurosurgery, infectious disease specialists, and microbiology is crucial for optimizing outcomes. ===== Retrospective observational studies ===== [[Postoperative]] [[intracranial]] neurosurgical [[infection]]s (PINI) complicate < 5% neurosurgeries. Scarce attention was dedicated to the extension and characteristics of its antimicrobial management considering their high morbidity, not negligible mortality, delayed hospital stay and increased healthcare costs. They analyzed [[retrospective]]ly (2014-2023) 162 PINI from eight Spanish [[tertiary teaching hospital]]s. [[Elective]] clean craniotomies after tumor or vascular causes were the leading procedures. [[Epidural abscess]] (24.7%), [[scalp infection]]s (19.8%), [[postsurgical meningitis]] (16.7%) and [[cranioplasty infection]]s (16.7%) were the most frequent PINI. [[Gram negative bacteria]] (38.6%) and Staphylococcus spp (28.6%) were the predominant isolates. Overall 85.2% patients underwent [[pus]] drainage, mostly by [[craniotomy]] (40.3%). Interestingly 34% were already receiving [[antibiotic]]s for extracranial infections before developing PINI while 16.8% did not receive pre-operative antibiotic prophylaxis. In total 77.2% patients started a combined intravenous (IV) antimicrobial therapy, of which 85.2% switched after 5 days to a second-line IV antibiotic regimen, in 41.3% cases combined, after pus culture results, for a median of 21 days. Overall 61.1% patients continued on oral antimicrobials after hospital discharge, 30.3% as a combined regimen, for a median of 42 days. Complete cure was obtained in 81.5% cases, while 11.1% relapsed, 7.4% failed to cure and 6.8% died after PINI complications. In the [[multivariate]] analysis oral antimicrobial therapy after hospital discharge (p = 0.001) was significantly associated with PINI cure with no effect on survival. They conclude that an extended 6 weeks sequential IV and oral antimicrobial therapy in addition to neurosurgical correction increases PINI cure rate with no effect on survival ((Asensi V, Vázquez-Fernández C, Suárez-Díaz S, Asensi-Díaz E, Carrasco-Antón N, García-Reyne A, Panero I, Muñoz MV, Guerra JM, Arístegui J, Sepúlveda MA, García-Calvo X, Dueñas C, Biosca M, Chiminazzo V, Collazos J. Extended sequential intravenous and oral antimicrobial therapy improves cure rate in postoperative intracranial neurosurgical infections: a Spanish multicenter retrospective study. BMC Infect Dis. 2024 Nov 26;24(1):1345. doi: 10.1186/s12879-024-10204-7. PMID: 39587499.))