# Prevention of Healthcare-Associated Ventriculitis and Meningitis -- IDSA 2017

## Perioperative Antimicrobial Prophylaxis

### Neurosurgical Procedures

- **Perioperative antimicrobial prophylaxis** is recommended for patients undergoing neurosurgical procedures (Strong, High).
  - This is the only recommendation in the entire guideline rated with **high-quality evidence**.
  - Prophylaxis should be timed to achieve adequate serum and tissue concentrations at the time of surgical incision.
  - Duration should be limited to the perioperative period (typically up to 24 hours post-procedure).

### CSF Shunt and Drain Insertion

- Antimicrobial prophylaxis is recommended at the time of CSF shunt or external ventricular drain (EVD) placement (Strong, Moderate).
- Agent selection should follow institutional guidelines and be based on local antimicrobial resistance patterns.

### Prolonged Prophylaxis During External Ventricular Drainage

- **Prolonged systemic antimicrobial prophylaxis** for the duration of external ventricular drainage is **NOT recommended** (Strong, Moderate).
  - Prolonged prophylaxis has not been shown to reduce infection rates and may promote selection of resistant organisms.
  - Antibiotic prophylaxis should be limited to the periprocedural period.

## Antimicrobial-Impregnated Devices

### Antimicrobial-Impregnated Catheters

- The use of **antimicrobial-impregnated CSF shunts** and **antimicrobial-impregnated external ventricular drains** is recommended to reduce infection rates (Strong, Moderate).
  - Available antimicrobial-impregnated catheters include:
    - **Rifampin + minocycline-impregnated** catheters
    - **Rifampin + clindamycin-impregnated** catheters
    - **Silver-impregnated** catheters
  - Meta-analyses and observational studies have demonstrated reduced infection rates with antimicrobial-impregnated catheters compared to standard catheters.

### Fixed-Interval Drain Exchange

- **Routine fixed-interval exchange** (scheduled replacement) of external ventricular drains is **NOT recommended** as a strategy to prevent infection (Strong, Moderate).
  - Scheduled drain exchanges have not been shown to reduce infection rates and may increase the risk of procedure-related complications.
  - EVDs should only be replaced when clinically indicated (malfunction, infection at the insertion site, or documented infection requiring new drain placement at a different site).

## Standardized Insertion Protocols and Care Bundles

### Insertion Protocol

- A **standardized protocol** for the insertion of CSF shunts and external ventricular drains is recommended to reduce infection rates (Strong, Moderate).
  - Key components of standardized insertion protocols include:
    - Full barrier precautions (cap, mask, sterile gown, sterile gloves, large sterile drape)
    - Skin antisepsis with chlorhexidine-based preparation
    - Minimizing the number of personnel in the procedure room
    - Minimizing CSF sampling to clinically necessary occasions only
    - Proper tunneling of external drain catheters away from the insertion site
    - Standardized dressing care and maintenance protocols

### CSF Sampling Practices

- Limit CSF sampling from external drains to **clinically necessary occasions only** (Strong, Moderate).
  - Routine or protocol-driven daily CSF sampling increases the risk of contamination and may introduce infection.
  - Aseptic technique is mandatory for all CSF sampling events.

## CSF Leak Management

### Basilar Skull Fractures with CSF Leak

- Prophylactic antibiotics are **NOT recommended** for patients with basilar skull fractures and CSF leaks (Strong, Moderate).
  - No evidence supports a reduction in meningitis risk with prophylactic antibiotics in this population.
  - Antibiotic prophylaxis may select for resistant organisms without clinical benefit.

### Persistent CSF Leak

- If a CSF leak persists for **more than 7 days**, surgical repair should be attempted (Strong, Low).
  - Persistent leaks represent an ongoing portal of entry for microorganisms.
  - Surgical repair options depend on the anatomical location (endoscopic transnasal, transcranial, etc.).

### Pneumococcal Vaccination

- Patients with CSF leaks should receive **pneumococcal vaccination** (Strong, Moderate).
  - CSF leaks represent a risk factor for pneumococcal meningitis.
  - Vaccination should include both PCV13 (or PCV15/PCV20 per current immunization guidelines) and PPSV23, per standard recommendations for adults at increased risk for invasive pneumococcal disease.

## Prevention Decision Algorithm

```
Patient undergoing neurosurgical procedure with CSF device placement
  --> Perioperative antimicrobial prophylaxis (up to 24 hours post-procedure) (Strong, High)
  --> Use antimicrobial-impregnated catheter when available (Strong, Moderate)
  --> Standardized insertion protocol with full barrier precautions (Strong, Moderate)
  --> Post-insertion care:
      --> Do NOT continue prophylactic antibiotics beyond perioperative period (Strong, Moderate)
      --> Do NOT routinely exchange EVDs at fixed intervals (Strong, Moderate)
      --> Limit CSF sampling to clinically necessary occasions (Strong, Moderate)
  --> Basilar skull fracture with CSF leak?
      --> Do NOT give prophylactic antibiotics (Strong, Moderate)
      --> If CSF leak persists >7 days --> Attempt surgical repair (Strong, Low)
      --> Administer pneumococcal vaccination (Strong, Moderate)
```

## Limitations

- Evidence for antimicrobial-impregnated catheters is based on observational studies and non-blinded trials; large randomized controlled trials are lacking.
- Specific antibiotic regimens for perioperative prophylaxis (drug choice, dose, timing) are not prescribed by this guideline and should follow institutional protocols.
- The optimal duration of perioperative prophylaxis (single dose vs. 24 hours) is not definitively established in this guideline.
- Care bundle components are based on expert consensus extrapolated from central line-associated bloodstream infection (CLABSI) prevention literature.
