Neonatal ventriculitis: a case series and review of literature

Abstract

Ventriculitis after meningitis is a serious complication in the neonatal age group. The role of intraventricular antibiotics in treatment is controversial. We present five such cases which were refractory to conventional intravenous antibiotic therapy, had persistent features of ventriculitis and in whom raised intracranial pressure (ICP) necessitated insertion of an external ventricular drain (EVD). Three of the five infants required intraventricular antibiotics but also developed EVD-related complications. Early diagnosis of ventriculitis and treatment is necessary to avoid a fatal outcome. Intravenous antibiotics are the treatment of choice, but intraventricular therapy may be considered in refractory cases. As the incidence of EVD-associated ventriculitis is high, proper care of EVDs and their early removal is mandatory.

Keywords

Neonates meningitis ventriculitis external ventricular drain

Introduction

Neonatal ventriculitis is a well-known complication of meningitis. Its incidence is in the range of 52%–94% after gram-negative meningitis.^1,2 It can be detected by ultrasonography.³ Unrecognised ventriculitis or meningitis may cause infantile hydrocephalus, leading to significant morbidity or death. A majority of cases may be due to an infective aetiology.⁴ Thus, it becomes important to identify ventriculitis early and treat it effectively in neonates at risk.⁴ There are no current recommendations for treatment of neonatal ventriculitis.⁵ Treatment modalities used include intravenous antibiotics alone, or intraventricular antibiotics via either an external ventricular drain (EVD) or reservoir.^6–8 The former carries the additional advantage of reducing raised intracranial pressure (ICP) and has been shown to be have improved cure rates,⁵ though not being devoid of procedure-associated risks itself.

Case series

We report five cases of neonatal meningitis in five infants, four term and one preterm, who developed ventriculitis. Table 1 shows the comparative details of these cases. In case 1, the EVD was inserted for decompression of ventricles for a short duration of seven days, though no intraventricular antibiotics were given. Cases 2, 3 and 4 had a relatively long duration of EVD insertion as they were not responding to the therapy. Reinsertion of the EVD was done in case 2 (due to accidental removal) and case 3 (due to blockage of the EVD, infection and accidental removal). Reinsertion was done at a different site. In case 3, the EVD was removed, a ventriculoperitoneal (VP) shunt was performed, but the EVD had to be reinserted as a shunt infection had developed. Finally, a definitive VP shunt was inserted at six months of age. This infant was discharged one month later on nasograstic feeding with severe neurological impairment. Case 4 had a ruptured meningomyelocele at birth, which was the predisposing factor for infection. Case 5 did not show much improvement with intravenous antibiotics; consequently, an EVD was inserted, but the infant died.

Table 1.

Comparative details of neonates with ventriculitis.

	Case 1	Case 2	Case 3	Case 4	Case 5
Gestation	Full term	Full term	Full term	Full term	Preterm
Gender	Female	Male	Female	Male	Male
Mode of delivery	Caesarean delivery	Caesarean delivery	Breech vaginal delivery	Caesarean delivery	Vaginal delivery
APGAR at 1 and 5 min	6, 9	9, 9	6, 9	9, 9	7, 8
Indication for admission	Post-resuscitation care	Meconium aspiration syndrome	Resuscitation at birth	Ruptured meningomyelocele	Prematurity and respiratory distress syndrome
Postnatal events	Day 5: meningitis (positive lumbar puncture) Day 15: repeated episodes of seizures, fever, poor suck, bulging anterior fontanelle, increasing head circumference US suggestive of communicating hydrocephalous Day 16: CT communicating hydrocephalous Ventricular tap suggestive of ventriculitis	Day 3: meningitis (positive lumbar puncture) Day 13: US suggestive of communicating hydrocephalous Day 20: seizure episodes CT: ventriculitis Day 22: ventricular tap suggestive of ventriculitis	Day 5: meningitis (positive lumbar puncture) Day 7: US skull s/o communicating hydrocephalous Day 20: VP shunt Day 30: shunt site infected, shunt removed	Day 14: MMC repair with VP shunt Day 18: apnoea, ventilator support for 2 weeks Day 24: increasing head circumference, bulging anterior fontanelle, seizures Ventricular tap suggestive of ventriculitis	Day 1: surfactant and ventilator support Day 8: multiple apnoea episodes and seizure, LP suggestive of meningitis Day 15: US suggestive of hydrocephalous Day 22: CT suggestive of ventriculitis Day 24: ventricular tap suggestive of ventriculitis
Day of EVD insertion	19	29	30	28	40
CSF culture	No growth	Acinetobacter boumanii, Candida albicans	Non-candida albicans	No growth	Acinetobacter boumanii
Intravenous antibiotics	Meropenam, Vancomycin 6 weeks	Meropenam, Vancomycin 3 weeks Colistin 3 weeks	Meropenam, Vancomycin 4 weeks Colistin 4 weeks Ciprofloxacin 2 weeks Amphotericin B 4 weeks	Meropenam Vancomycin 4 weeks	Meropenam Vancomycin 3 weeks Colistin 10 days
Intraventricular antibiotics	None	Colistin 3 weeks	Colistin 2 weeks Meropenem and ciprofloxacin 2 weeks	Colistin 2 weeks	None
EVD removal	Day 26	Day 52	Day 96 Reinserted at 5 months of age, for 4 weeks Infant discharged at 7 months of life after shunt surgery	Day 60
Duration of EVD	7 days	3 weeks	8 weeks 4 weeks	4 weeks	2 days
Shunt surgery	–	+	+	+	–
Complications	None	Persistent infection, EVD site leak, accidental removal	Accidental removal, block, EVD infection	Persistent infection (EVD-related)	None
Outcome	Alive, no neurological morbidity	Alive, minimal developmental delay	Alive, marked neurological deterioration	Left against medical advice	Died

CSF, cerebrospinal fluid; CT, computed tomography; EVD, external ventricular drain; LP, Lumbar Puncture; US, ultrasound; VP, ventriculoperitoneal.

Discussion

Ventriculitis is a serious complication in the neonatal age group, for which there is no consensus for management. The time lapse between the diagnosis of ventriculitis from the first lumbar puncture suggesting meningitis may be an important consideration. Although it has been estimated to be 17.5 days on average,⁴ we found a longer period in our patients. Secondary deterioration or non-improvement in the form of persistent seizures, fever, apnoeic episodes or increase in head circumference may, however, provide clues towards earlier diagnosis of ventriculitis. Thus, it becomes important to keep a high index of suspicion in neonates who may show only subtle signs. Such patients should be investigated early.

The definitive diagnosis is by ventricular tap and cytological, biochemical and microbiological analysis of ventricular cerebrospinal fluid (CSF).⁴ As this is an invasive procedure, various non-invasive modalities in the form of neuroimaging have been used. Ultrasonographic evaluation detects ventriculitis in only 10%–20% of meningitis cases,^9,10 although it should still be the initial imaging modality.¹¹ Although hydrocephalus had developed in almost all cases, specific ultrasonographic features of ventriculitis such as internal echoes, debris or ventricular septations¹² may only be seen in 15%. Similarly, characteristic computed tomography (CT) findings such as ventricular debris, hydrocephalus, ependymal enhancement and meningeal enhancement¹³ and characteristic magnetic resonance imaging (MRI) findings such as intraventricular debris, pus, abnormal periventricular and subependymal signal intensity, and enhancement of the ventricular lining¹⁴ were only found in 10% and 23%, respectively.

With limited access to CT and MRI, these modalities are of uncertain benefit, and ultrasound may be hugely operator-dependent.

Conventional management is by 4–6 weeks of intravenous antibiotics. However, the ventricles and the choroid plexus may serve as a reservoir of infection. Intravenous antibiotics in standard dosages may be ineffective owing to obstruction by cellular debris and high protein levels blocking draining of CSF. The presence of multi-resistant bacteria and the poor penetration of many drugs through the blood–brain barrier necessitate the use of intrathecal therapies.¹⁴

An unsatisfactory response to conventional therapy is usually manifested by persistent fever, refractory seizures or deteriorating mental status,¹⁰ and rising ICP.

The use of EVD and instillation of intraventricular antibiotics has been previously reported.^15,16 An alternative modality is by exteriorisation of a VP shunt. The use of intraventricular antibiotics has been mainly studied in shunt-related, post-traumatic ventriculitis and multidrug-resistant acinetobacter meningitis,^5,6,17 especially with acinetobacter boumanii.¹⁸ Combined intravenous and intraventricular use of colistimethate sodium attains maximum concentrations of CSF than intravenous alone.⁶ Although a Cochrane review found an increased mortality where both intraventricular and intravenous antibiotics had been used,⁸ we opted for this where a trial of intravenous antibiotics had shown no improvement. Furthermore, our cases also had associated hydrocephalus, which demanded decompression. The duration of drainage of the EVD is also not well defined: an average use for 9.1 days (range = 3–19 days) was described in India,⁵ although a duration as long as 36 days was used in a cohort of patients not restricted to neonates.¹⁸

Treatment with EVD carries its own risks; it may act as a double-edged sword. EVD infection, blockage, accidental removal or rarely excessive drainage may all occur, and the EVD requires strict supervision, preferably by a multidisciplinary team.

It has been suggested that if insertion of the EVD is required for >5 days, a second one should be inserted at a different site¹⁹ and the first removed; however, this has been disputed.²⁰

We used antimicrobial-impregnated catheters and practise EVD care with strict aseptic insertion, limited manipulation, routine aseptic dressing and early removal. We do not recommend routine changing of the EVD.

Sometimes a prolonged EVD is required if the infection in the ventricles does not resolve, or if the EVD is blocked, or where a raised ICP recurs after temporary occlusion of the drain. As three of our patients developed complications of the EVD—such as the appearance of new organisms in the CSF, fungal ventriculitis, shunt blockage and accidental removal of the EVD—its proper care is mandatory; early removal once its indication is obsolete needs be practised.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Footnotes

ORCID iD

Ramitha R Bhat

Prerna Batra

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