BACKGROUNDIt has been confirmed that the concentration of cefepime in cerebrospinal fluid (CSF) could reach the 10% of its concentration in plasma, exceeding the inhibitory concentration to 90% of organisms (MIC(90)) for common bacteria. However, the blood-brain barrier (BBB) penetration ability of cefepime is still unclear. The aim of this study was to measure the CSF concentration of cefepime in patients after neurosurgical operations, and to determine the penetration of the drug through an incomplete BBB.

METHODSEight patients who received ventricular drainage (VD group) and 5 who underwent lumbar puncture drainage (LPD group) were enrolled into this study. Cefepime (2 g) was injected intravenously in 30 minutes after the neurosurgeries. The concentrations of cefepime in the CSF and plasma were measured by high-pressure liquid chromatography (HPLC) at different time points.

RESULTSThe CSF concentrations of cefepime at different time points in the VD group were significantly higher than those in the LPD group (P < 0.05). In the VD group, the concentration of cefepime in CSF reached the peak ((22.54 +/- 14.06) microg/ml) at 1 to 2 hours after the injection, while in the LPD group at 4 hours ((5.61 +/- 3.73) microg/ml). In both groups, the peak was higher than the MIC(90) of most common bacteria in intensive care unit. The ratio of CSF to plasma cefepime concentrations ranged from 0.30 to 2.14 in the VD group and 0.03 to 1.14 in the LPD group.

CONCLUSIONAfter neurosurgeries, CSF concentration of cefepime can reach a therapeutic level. Thus, the drug could be used to prevent and treat postoperative intracranial infection.

OBJECTIVE: To evaluate cerebrospinal fluid (CSF) vancomycin concentrations and identify factors influencing CSF vancomycin concentrations in critically ill neurosurgical patients. METHODS: A retrospective study was conducted. Adult patients who received vancomycin treatment and CSF vancomycin concentrations monitoring admitted to neurosurgical intensive care unit (ICU) of the First Affiliated Hospital of Sun Yat-sen University from January 2016 to June 2019 were enrolled. General information, vancomycin dosing regimens, CSF vancomycin concentrations, CSF drainage methods and volume of the previous day, and concurrent medications, etc. were collected for analysis. CSF vancomycin concentrations of patients with definite or indefinite central nervous system (CNS) infection, different vancomycin dosing regimens and their influencing factors were analyzed. RESULTS: A total of 22 patients were included. 168 CSF specimens were collected for culture, 20 specimens of which were culture positive, with a positive rate of 11.9%. Sixty cases of CSF vancomycin concentration were obtained. Among the 22 patients, 7 patients (31.8%) were diagnosed with proven CNS infection, 11 patients (50.0%) clinically diagnosed, 2 patients (9.1%) diagnosed with uncertain CNS infection, and 2 patients (9.1%) diagnosed without CNS infection. Intravenous (IV) administration of vancomycin alone was used in 15 cases (25.0%), intrathecal injection in 17 cases (28.3%), IV+intrathecal injection in 23 cases (38.3%), and IV+intraventricular administration in 5 cases (8.3%). The CSF vancomycin concentrations ranged from < 0.24 to > 100 mg/L, with an average level of 14.40 (4.79, 42.34) mg/L. (1) Administration methods of vancomycin affected CSF vancomycin concentrations. The CSF vancomycin concentration with intrathecal injection or intraventricular administration was higher than that of IV administration alone [mg/L: 25.91 (11.28, 58.17) vs. 2.71 (0.54, 5.33), U = 42.000, P < 0.01]. (2) When vancomycin was administered by IV treatment alone, CSF vancomycin concentrations were low in both groups with definite CNS infection (proven+probable) and indefinite CNS infection (possible+non-infection), the CSF vancomycin concentrations of which were 4.14 (1.40, 6.36) mg/L and 1.27 (0.24, 3.33) mg/L respectively, with no significant difference (U = 11.000, P = 0.086). (3) CSF vancomycin concentrations rose with the increased dose of vancomycin delivered by intrathecal injection or intraventricular administration. According to the dose of vancomycin administered locally on the day before therapeutic drug monitoring (TDM), cases were divided into the following groups: 0-15 mg group (n = 22), 20-35 mg group (n = 33), and 40-50 mg group (n = 5), the CSF vancomycin concentrations of which were 4.14 (1.09, 8.45), 30.52 (14.31, 59.61) and 59.43 (25.51, 92.45) mg/L respectively, with significant difference (H = 33.399, P < 0.01). Moreover, the cases of CSF vancomycin concentration of ≥ 10 mg/L accounted for 18.2%, 84.8% and 100% of these three groups, respectively. CSF vancomycin concentrations mostly reached target level when dose of vancomycin administered locally were 20 mg/L or more. CONCLUSIONS It is difficult to reach target CSF vancomycin concentration for critically ill neurosurgical patients with or without CNS infection by IV treatment. Local administration is an effective treatment regimen to increase CSF vancomycin concentration.
Adult ; Anti-Bacterial Agents/cerebrospinal fluid* ; Drug Monitoring ; Humans ; Intensive Care Units ; Retrospective Studies ; Vancomycin/cerebrospinal fluid*

PURPOSE: Despite the advent of new and more potent antibiotics, mortality and morbidity rates due to bacterial meningitis remain stagnant. Rapid detection of microorganism and early antibiotics treatment are the most important prognostic factors of bacterial meningitis. For early diagnosis of bacterial meningitis biochemical markers such as lactic dehydrogenase, lactic acid, C-reactive proteia have been measured in cerebrospinal fluid. Ferritin is a large, spherical molecule with propensity for oligomer formation, which causes low concentration in cerebrospinal fluid. METHODS: From May 1996 to July 1999, cerebrospinal fluid(CSF) ferritin was serially measured in 84 children who were admitted to Chonnam Natuional University Hospital Pediatric Department for evaluation of the diagnostic value of CSF ferritin in bacterial meningitis. They were divided into three groups-control(20), aseptic(40), bacterial(24)-according to inclusion criteria for each group. RESULTS: CSF ferritin level in bacterial meningitis(52.94+/-3.19ng/mL) was much higher than those of aseptic(5.26+/-2.07ng/mL), and control(3.01+/-2.52ng/mL) groups(P<0.05). CSF ferritin level of 9.20ng/mL was suggested as a cut-off value for bacterial meningitis on ROC curve(sensitivity: 92 %, specificity:81%). CSF ferritin levels were positively correlated with CSF WBC(r=0.699) and protein(r=0.734) and negatively correlated with CSF glucose(r=-0.609) (P<0.01). CONCLUSION: CSF ferritin could be a good indicator for bacterial meningitis in children.
Anti-Bacterial Agents ; Biomarkers ; Cerebrospinal Fluid* ; Child* ; Early Diagnosis ; Ferritins* ; Humans ; Jeollanam-do ; Lactic Acid ; Meningitis* ; Meningitis, Bacterial ; Mortality ; Oxidoreductases

PURPOSE: The widespread introduction of bacterial conjugate vaccines has decreased the risk of cerebrospinal fluid (CSF) pleocytosis due to bacterial meningitis (BM) in children. However, most patients with CSF pleocytosis are hospitalized and treated with parenteral antibiotics for several days. The bacterial meningitis score (BMS) is a validated multivariate model derived from a pediatric population in the postconjugate vaccine era and has been evaluated in several studies. In the present study, we examined the usefulness of BMS in South Korean patients. METHODS: This study included 1,063 patients with CSF pleocytosis aged between 2 months and 18 years. The BMS was calculated for all patients, and the sensitivity and negative predictive value (NPV) of the test were evaluated. RESULTS: Of 1,063 patients, 1,059 (99.6%) had aseptic meningitis (AM). Only four patients (0.4%) had BM. The majority of patients (98%) had a BMS of < or =1, indicating a diagnosis of AM. The BMS was 0 in 635 patients (60%) and 1 in 405 patients (38%). All four BM patients had a BMS of > or =4. CONCLUSION: To our knowledge, this is the first study to investigate the diagnostic strength of the BMS in South Korea. In our study, the BMS showed 100% sensitivity and 100% NPV. Therefore, we believe that the BMS is a good clinical prediction rule to identify children with CSF pleocytosis who are at a risk of BM.
Anti-Bacterial Agents ; Cerebrospinal Fluid* ; Child* ; Decision Support Techniques ; Diagnosis ; Humans ; Korea ; Leukocytosis* ; Meningitis, Aseptic ; Meningitis, Bacterial* ; Vaccines, Conjugate

Corynebacterium xerosis is a normal flora of the skin, mucous membrane and gastrointestinal tract. Although not usually considered to be a pathogen, it occasionally causes serious infections in immunocompromised hosts. We report a case of a shunt infection by C.xerosis developed in a 58-year-old woman following the insertion of a ventriculoperitoneal shunt. The organism was also isolated from the cerebrospinal fluid and blood. The isolate was resistant to most of the antibiotics tested except for vancomycin. However, in spite of treatment with vancomycin, the patient was expired after 5 months.
Anti-Bacterial Agents ; Cerebrospinal Fluid* ; Corynebacterium* ; Female ; Gastrointestinal Tract ; Humans ; Immunocompromised Host ; Middle Aged ; Mucous Membrane ; Skin ; Vancomycin ; Ventriculoperitoneal Shunt*

We treated a 66 year-old-male patient with non-traumatic spontaneous E. coli meningitis, whose cerebrospinal fluid showed turbid, and from which E. coli was cultured, and who had urinary tract infection and fatty liver disease which were thought to be predisposing factors to the meningitis. Gram-negative bacillary meningitis is a very rare condition after the neonatal period, and may be complicated by penetrating cranial injuries, neurosurgical interventions or such debilitating diseases as diabetes, liver cirrhosis, urinary tract infection, malignancy and alcholism, etc. It has a high mortality rate in spite of using various antibiotics.
Adult* ; Anti-Bacterial Agents ; Causality ; Cerebrospinal Fluid ; Fatty Liver ; Humans ; Liver Cirrhosis ; Meningitis* ; Mortality ; Urinary Tract Infections

PURPOSE: Bacterial meningitis in childhood carries significant mortality and morbidity, so accurate and rapid diagnosis is important. Cerebrospinal fluid (CSF) latex agglutination test has been used for rapid diagnosis of bacterial meningitis. However, urine may be the best specimen for a latex test, because bacterial antigens are concentrated in the urine. The study tried to determine the diagnostic value of urine latex test in bacterial meningitis. METHODS: We evaluated 219 patients who were suspected with bacterial meningitis and examined CSF Gram stain, CSF culture, CSF latex test and urine latex test. And 17 patients with bacterial meningitis were followed up at post-antibiotics 3, 7, 14, 21, 28 days. RESULTS: Sensitivity and specificity of urine latex test in bacterial meningitis were 82.4% and 99.4%. In H. influenzae type b meningitis, the sensitivity and specificity of urine latex test were 100% and 99.4%. The positive rates of urine latex tests after antibiotics treatment persisted significantly longer than the positive rates of CSF culture, smear and latex test. CONCLUSOIN: Urine latex test was as useful as CSF smear and CSF latex test during the early diagnosis of bacterial meningitis. The urine latex test was more valuable than CSF smear, latex, and culture in partially treated bacterial meningitis, because of persistent positivity after antibiotics treatment.
Anti-Bacterial Agents ; Antigens, Bacterial ; Cerebrospinal Fluid ; Diagnosis ; Early Diagnosis ; Humans ; Influenza, Human ; Latex Fixation Tests ; Latex* ; Meningitis ; Meningitis, Bacterial* ; Mortality ; Sensitivity and Specificity

STUDY DESIGN: Case report. OBJECTIVES: We report a case of meningitis combined with paraspinal infection in a patients who underwent numerous surgeries for and repetitive procedural treatment of the spine. SUMMARY OF LITERATURE REVIEW: In patients with a history surgical and repetitive procedural treatment of the spine, one symptom of infection may be a fever with localized pain or tenderness along the spine. MATERIALS AND METHODS: A 69-year-old man was hospitalized due to pyrexia and myalgia. Eight years ago, he underwented spine surgery. After that, the patient underwent spinal intervention more than once per week in another hospital due to remaining pain. One week before his visit to the emergency room, myalgia and aggravation in the lower back arose. However, a paraspinal infection was not detected in a non-enhanced MRI. One day after admission, the patient showed signs of meningeal irritation signs and the the patient's mental state suddenly deteriorated. An emergency cerebrospinal fluid analysis showed typical findings of bacterial meningitis. An enhanced MRI of the brain showed pachymeningeal enhancement. An enhanced MRI of the spine showed a small abscess formation on the left paravertebral back muscle, and bilateral psoas muscle. RESULTS: Serrtia marcescens was identified on blood cultures obtained upon admission. Since antibiotics were used to treat Serratia marcescens, the fever subsided, and the patient's mental status returned to normal. CONCLUSIONS: For patients with a history of repetitive procedural treatments of the spine, a fever should be acknowledged as a symptom in meningitis or other infectious conditions.
Abscess ; Aged ; Anti-Bacterial Agents ; Back Muscles ; Brain ; Cerebrospinal Fluid ; Emergencies ; Emergency Service, Hospital ; Fever ; Humans ; Magnetic Resonance Imaging ; Meningitis* ; Meningitis, Bacterial ; Myalgia ; Psoas Muscles ; Serratia marcescens ; Spine*

BACKGROUND/AIMS: Frequent pathogens of nosocomial meningitis were investigated and the adequacy of empiric antibiotic therapy was assessed. Outcomes of nosocomial meningitis were also evaluated. METHODS: Ninety-one patients, who were diagnosed and treated for nosocomial meningitis at a single tertiary hospital in Daegu, Korea for 10 years, were included. Medical record and electronic laboratory data on the causative pathogens, antibiotics used, and outcomes were retrospectively investigated. RESULTS: Coagulase-negative Staphylococcus (40.9%) was the most common pathogen, followed by Acinetobacter (32.5%). Both were cultured as a single organism in cerebrospinal fluid (CSF). Seventy-eight patients (85.7%) had infections related to external ventricular drains (EVD). The most common empirical antibiotics were extended-spectrum beta-lactam antibiotics plus vancomycin (35/91, 38.6%). Of the 27 patients who had cultured Acinetobacter in CSF, 10 (37%) were given the wrong empirical antibiotic treatment. Seven of the 27 patients (26.9%) with cultured Acinetobacter died, and overall mortality of the 91 patients was 16.5%. In the multivariate analysis, the presence of combined septic shock (p < 0.001) and a persistent EVD state (p = 0.021) were associated with a poor prognosis. CONCLUSIONS: Acinetobacter is one of the leading pathogens of nosocomial meningitis and may lead to inadequate coverage of empiric antibiotic therapy due to increasing resistance. An EVD should be removed early in cases of suspected nosocomial meningitis, and carbapenem might be required for the poor treatment response.
Acinetobacter/classification/*isolation & purification ; Acinetobacter Infections/cerebrospinal fluid/diagnosis/*drug therapy/*microbiology ; Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents/*therapeutic use ; Cerebrospinal Fluid/microbiology ; Cross Infection/cerebrospinal fluid/diagnosis/*microbiology/mortality/*therapy ; Drug Resistance, Bacterial ; Female ; Humans ; Logistic Models ; Male ; Meningitis, Bacterial/cerebrospinal fluid/diagnosis/*drug therapy/*microbiology/mortality ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Republic of Korea ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Staphylococcal Infections/cerebrospinal fluid/diagnosis/*drug therapy/*microbiology/mortality ; Staphylococcus/classification/*isolation & purification ; Time Factors ; Treatment Outcome ; Young Adult

OBJECTIVE: Device-associated infections in the central nervous system are serious complications of procedures involving indwelling devices among neurosurgical patients. In this study, the clinical characteristics and outcome of microbiologically confirmed device-associated cerebrospinal fluid (CSF) infection were evaluated. METHODS: We performed a retrospective analysis of adult patients found to have a positive CSF culture result during a hospital admission between 1 January 2005 through 2 October 2010 in Soonchunhyang University Hospital. RESULTS: During the study period, all episodes (n=161 CSF specimens, 87 patients) involving a culture-positive CSF were enrolled. Thirty-two episodes of device-associated CSF infection were included in the analysis among the study group. Most device-associated infections were ventriculo-peritoneal shunt infections (14/32, 44%). Fever (>38degrees C) was present in 17 episodes (53%). Overall, the most common microorganism was coagulase-negative staphylococcus (7/32 [22%]). Gram-negative rods (Pseudomonas aeruginosa 6/32 [19%], Acinetobacter baumannii/haemolyticus 5/32 [16%]) were identified in culture in 16/32 (50%). Device was removed for the control of device-associated infection in 30/32 (94%). Cure rate was 69% (22/32). All patients with treatment failure (10/32, 34%) expired. CONCLUSION: It is difficult to diagnosis device-associated CSF infections early since those are frequently presented with nonspecific clinical signs and symptoms. In our study, gram-negative infections accounted for 50% of cases and the empiric antibiotics initially chosen were found to not be effective against the final identified pathogen in many cases. Device-associated CSF infections should be strongly considered a serious risk factor associated with CSF infections, and prompt initiation of broad coverage antibiotics should be started after appropriate assessment.
Acinetobacter ; Adult* ; Anti-Bacterial Agents ; Central Nervous System ; Cerebral Ventriculitis ; Cerebrospinal Fluid* ; Diagnosis ; Fever ; Humans ; Meningitis ; Retrospective Studies ; Risk Factors ; Staphylococcus ; Treatment Failure ; Ventriculoperitoneal Shunt