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Management of post-neurosurgical meningitis: narrative review
K Hussein1, R Bitterman2, B Shofty3
1Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
Background:
Infections complicating neurosurgery pose unacceptable mortality and morbidity.
Aims:
To summarize what is known about the epidemiology, diagnosis and treatment of post-neurosurgical meningitis (PNM).
Sources:
PubMed, references of identified studies and reviews, and personal experience when evidence was lacking.
Content:
The incidence and pathogen distribution of PNM is highly variable. A shift towards Gram-negative bacteria has been observed with use of antibiotic prophylaxis and antibiotic-coated devices directed mainly against Gram-positive bacteria. However, knowledge of the local epidemiology is necessary to treat PNM. The diagnosis of PNM is difficult because, unlike community-acquired meningitis, symptoms are less specific; patients are ill at baseline and many neurosurgical conditions mimic meningitis and cause cerebrospinal fluid (CSF) abnormalities. Pivotal CSF findings for diagnosis of PNM are the CSF glucose, CSF lactate and Gram stain. CSF leucocyte counts are not specific in PNM. Current diagnostic capabilities leave a non-negligible category of patients with microbiologically negative, uncertain diagnosis of PNM. There is no high-quality evidence on several cardinal issues in PNM management, including the effectiveness of intraventricular or intrathecal (IV/IT) antibiotics, effectiveness of dual antibiotic therapy for multidrug-resistant Gram-negative bacteria; clinical benefit of routine therapeutic drug monitoring; and safest timing of shunt replacement. Some data point to a potential benefit of IV/IT antibiotic treatment, mainly for PNM caused by carbapenem-resistant Gram-negative bacteria. Carbapenem-colistin combination therapy is suggested for PNM caused by carbapenem-resistant Gram-negative bacteria with a carbapenem MIC ≤8 mg/L.
Implications:
Guiding the optimal management of PNM will necessitate collaborative multicentre efforts and unique study designs.
Insights
Post-neurosurgical meningitis (PNM) presents diagnostic challenges due to variable pathogens and nonspecific symptoms. Optimal management requires further research and collaborative multicenter studies for improved patient outcomes.
Area of Science:
- Neurosurgery
- Infectious Diseases
- Clinical Microbiology
Background:
- Post-neurosurgical meningitis (PNM) is a severe complication with high mortality and morbidity.
- PNM epidemiology shows variability in incidence and pathogen distribution, with a trend toward Gram-negative bacteria.
Purpose of the Study:
- To review the current understanding of post-neurosurgical meningitis (PNM) epidemiology, diagnosis, and treatment.
- To highlight knowledge gaps and challenges in managing PNM.
Main Methods:
- Comprehensive literature search of PubMed and other relevant databases.
- Inclusion of references from identified studies and reviews.
- Incorporation of expert clinical experience where evidence was lacking.
Main Results:
- PNM diagnosis is complicated by nonspecific symptoms and overlapping signs with other neurosurgical conditions.
- Cerebrospinal fluid (CSF) glucose, lactate, and Gram stain are pivotal for diagnosis; leukocyte counts are not specific.
- High-quality evidence is lacking for optimal treatment strategies, including intraventricular/intrathecal antibiotics and management of multidrug-resistant Gram-negative bacteria.
Conclusions:
- Optimal management of PNM requires addressing significant evidence gaps.
- Collaborative, multicenter research with novel study designs is essential to guide best practices.
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