Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA
- Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA
Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
DOI:10.4103/sni.sni_449_16Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Omid Hariri, Saman Farr, Shokry Lawandy, Bailey Zampella, Dan Miulli, Javed Siddiqi. Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?. 07-Jul-2017;8:137
How to cite this URL: Omid Hariri, Saman Farr, Shokry Lawandy, Bailey Zampella, Dan Miulli, Javed Siddiqi. Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?. 07-Jul-2017;8:137. Available from: http://surgicalneurologyint.com/surgicalint-articles/will-clinical-parameters-reliably-predict-external-ventricular-drain%e2%80%91associated-ventriculitis-is-frequent-routine-cerebrospinal-fluid-surveillance-necessary/
Background:The placement of an external ventricular drain (EVD) for monitoring and treatment of increased intracranial pressure is not without risk, particularly for the development of associated ventriculitis. The goal of this study was to investigate whether changes in cerebrospinal fluid (CSF), serum, or clinical parameters are correlated with the development of ventriculitis before it occurs, allowing for the determination of optimal timing of CSF collection.
Methods:An observational retrospective study was conducted between January 2006 and May 2012. A total of 466 patients were identified as having an in-situ EVD placed. Inclusion criteria were age >18 years, glasgow coma scale (GCS) 4-15, and placement of EVD for any indication. Exclusion criteria included recent history of meningitis, cerebral abscess, cranial surgery or open skull fracture within the previous 30 days. A broad definition of ventriculitis was used to separate patients into three initial categories, two of which had sufficient patients to proceed with analysis: suspected ventriculitis and confirmed ventriculitis. CSF sampling was conducted on alternating weekdays.
Results:A total of 466 patients were identified as having an EVD and 123 patients were included in the final analysis. The incidence of ventriculitis was 8.8%. Only the ratio of glucose CSF: serum
Conclusions:This study demonstrates no reliable tested CSF, serum, or clinical parameters that are effectively correlated with the development of ventriculitis in an EVD patient. Thus, we recommend and will continue to draw CSF samples from patients with in-situ EVDs on our current schedule for as long as the EVD remains in place.
Keywords: Cerebrospinal fluid, external ventricular drain, infection, surveillance, ventriculits
The use of external ventricular drain (EVD) serves a dual function in neurosurgical patients. It not only serves as a diagnostic monitor to detect elevated intracranial pressure (ICP), but also serves a therapeutic role in its ability to drain cerebrospinal fluid (CSF) in the setting of elevated ICP. While the ICP device is used in many neurosurgical patients, including but not limited to, those with subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), or acute hydrocephalus; it is not without complications. The most commonly noted complication is ventriculitis. Incidence rates vary depending on the institution, and range from 0–22%, but more commonly tend to lie within the 10–17% range.[
A literature review by R. Beer et al., spanning 18 years (1990–2008) confirmed an infection rate within the range commonly cited (5–20%), but found that it varies considerably from center to center as well as from different studies.[
In a prospective epidemiologic study, Mayhall et al.[
Early detection of ventriculitis is imperative for successful treatment and for minimizing the possibility of future infections.[
An important consideration in the control of ventriculitis is the surveillance of CSF and monitoring for clinical symptoms of ventriculitis.[
Naturally, one would assume that a breach of the EVD drainage system for sampling the CSF would increase the risk of contamination and subsequent infection. However, this risk must be balanced by the morbidity and mortality of ventriculitis, if it remains undetected. This is especially important in light of the established literature showing the difficulty in clinical detection of ventriculitis. Current standard practice at our institution is to sample CSF upon insertion of EVD, followed by sampling every Monday, Wednesday, and Friday for as long as the EVD remains in place. As a result of these challenges, we decided to examine whether changes in any CSF, serum, or clinical parameters are correlated with the development of ventriculitis before it occurs, and if the current collection schedule of CSF is necessary.
The patients included in this study were identified during the course of the study using their medical record numbers. We performed a retrospective observational study of the Neurosurgical Census, for patients with in situ EVD from January 2006 to May 2012. A total of 466 patients were identified. Medical records were then used to classify patients by age and gender; the duration of EVD, CSF and serum laboratory data, daily temperatures, changes in GCS, CSF culture, and the presence of other infections. To be included in the study, patients had to be 18 years or older, have an EVD (regardless of indication), and GCS 4-15. Patients with any recent (defined as within the last 30 days) history of meningitis, cerebral abscess, craniotomy, or open skull fracture were excluded from the study [
At our institution, EVDs are placed by standard neurosurgical sterile technique in either the operating room (OR), the emergency department (ED), or in the intensive care unit (ICU), and are then connected to a sterile closed circuit system. Since the indication for most of these EVDs was emergent, the setting could have been anywhere in OR, ED, or ICU. However, since an institutional protocol is established, the best effort is made to follow the standard sterile technique regardless of location. Therefore, in our opinion and given the standard placement protocol that is followed, the patient's physical location in the hospital should not significantly affect the risk for the development of ventriculitis.
Antibiotic-impregnated catheters were not available at our institution during the study time period. However, based on recent literature, antibiotic-impregnated catheters do appear to decrease the rate of ventriculitis.[
In regards to patients with an EVD, per current institutional protocol for the Department of Neurosurgery, CSF samples are drawn every other day during the week (i.e., Monday, Wednesday, Friday) for as long as the EVD remains in place. CSF samples are drawn solely by the neurosurgery residents or attending physicians. Our collection procedure was performed per institutional protocol developed by the neurosurgery department. Significant increase in the cytology number has been observed at our institution when CSF is collected more distally or from the drainage burette. Therefore, collection is performed in the following manner and in a sterile fashion in order to minimize infection risk to the patient. The stopcock just distal to the catheter insertion site is turned off from the drainage system and the proximal port is cleaned with chlorahexidine twice. A sterile syringe is connected to the port and 3–5 ml of CSF is slowly withdrawn and then discarded. The port is then cleaned a second time and another 3–5 ml of CSF is withdrawn, and sent for culture and analysis using standard methods.
For patients in our study, the aforementioned laboratory and clinical parameters were collected on the day of EVD placement (“day 0”). Additionally, the following data was collected on the day of EVD placement (“day 0”), as well the day prior (“day 1”) and 2 days prior (“day 2): serum white blood cells (WBC), temperature, GCS, and cultures from other bodily sources (including sputum, nasal, urine, blood, neck, or tracheostomy). The schema for the time-based collection of all laboratory and clinical data can be found in
To define ventriculitis, we used the criteria proposed by Lozier et al.,[
Patients were broadly divided into three categories: No ventriculitis, suspected ventriculitis, and confirmed ventriculitis. A CSF culture with the growth of any organisms denoted confirmed ventriculitis. In the absence of any organisms, the previously mentioned criteria from Lozier et al.[
All statistical analyses were conducted using the SAS software for Windows version 9.3 (Cary, NC). Descriptive statistics were presented as means and standard deviations for continuous variables (for example, age), and frequencies and percentages for categorical variables. Crosstab analyses were conducted to identify the association between two categorical variables using the Chi-square test or Fisher's exact test if the expected cell count does not meet the assumption. Given the small count in the suspected ventriculitis (N = 4), this category was excluded from the analysis. This was done to prevent any crossover contamination of the data by the suspected ventriculitis group into the other two groups (confirmed & no ventriculitis). These two groups are essentially positive and negative for ventriculitis, respectively, and the intermediate suspected ventriculitis group does not clearly belong in either one based on established criteria in the literature.[
A total of 123 were included in the final analysis. The majority of these patients were males (N = 87, 70.7%) with the average age being 48.8 ± 17.2 years. A total of 10 (8.1%) patients diagnosed with ventriculitis, 4 (3.3%) with suspected ventriculitis, and 109 (88.6%) without ventriculitis were identified in this sample [
Crosstab analyses were conducted using the Fisher's exact test [
However, despite the lack of statistically significance (P = 0.0866), patients who were diagnosed with ventriculitis were twice as more likely to have a WBC to RBC ratio >1:250 (40% vs 16.5% for ventriculitis and no ventriculitis cohort, separately). Similarly, patients who were diagnosed with ventriculitis were twice as likely to have CSF Glucose <0.5 serum (50% vs 21.2% for ventriculitis and no ventriculitis cohort, separately). Lastly, using glucose as a continuous variable, patients with ventriculitis had statistically significant lower concentration of glucose than the counterpart (0.48 and 0.62 for ventriculitis and no ventriculitis cohort, separately, P = 0.0298) [
Crosstab analysis of ventriculitis status with respect to fever greater than 100.4°F did not show statistical significance, regardless of day of collection. A temperature greater than 100.4°F 2 days prior to CSF collection, one day prior to collection, and on the day of collection resulted in respective P values of 1.000, 0.600, and 0.639 [
With respect to microbiology in our patient population, Coagulase-negative staphylococci (including Staphylococcus epidermidis) was found to be the most common organism isolated from positive CSF cultures, occurring approximately 53% of the time. Additional organisms isolated included Corynebacterium species, methicillin-resistant Staphylococcus aureus, Propionibacterium acnes, Enterobacter aerogenes, and Cryptococcus neoformans.
Only one of our criteria for the diagnosis of ventriculitis, the ratio of glucose in the CSF: serum proved to be statistically significant when this ratio is less than 0.5 or 1:2 (P = 0.0298). Approximately 21% of patients without ventriculitis had a glucose CSF: serum ratio <0.5, as compared to 50% of patients with confirmed ventriculitis. While statistically significant, this was not found to be a correlated with the development of ventriculitis (P = 0.0539). It was noted that patients who were diagnosed with ventriculitis were twice as likely to have a glucose CSF: serum ratio of less than half.
Our study sought to investigate the presence of the aforementioned CSF, serum, and clinical parameters that may be correlated with the development of ventriculitis before it occurs; thereby allowing for the determination of an optimal CSF surveillance schedule. Our study population consisted mostly of intubated and sedated ICU patients who presented a challenge for evaluation of clinical symptoms and signs of ventriculitis. In addition, evaluation of any new focal neurological symptoms or change in mental status in our patient population proved difficult, thus necessitating the use of additional parameters for detection of ventriculitis. In our study, the incidence of ventriculitis was determined to be 8.8% overall. This was found to be slightly lower than the established literature values.[
Upon further investigating additional criteria for suspected ventriculitis, the ratio of CSF WBC: RBC had inconsistent findings. As noted in
While the levels of protein in the CSF have classically been a valuable indicator, care must be taken when looking at mean values for this parameter. As
We acknowledge that this was a retrospective observational study, and with that comes certain limitations. The exact timing of temperature and of GCS documentation to match with one and 2 days prior to onset of ventriculitis was difficult to verify and sometimes unavailable. In addition, even though a standard sterile neurosurgical technique was mandated for CSF collection, human error is always a factor. We feel this may have been reflected in the outlying CSF protein values >500 mg/dL. We also recognize that the patient population with ventriculitis was small and therefore limited our statistical analysis. We propose a continuation of this study in a prospective manner that will allow for more meticulous documentation and collection of necessary data points. We aim to look at additional parameters at various intervals to see if they would be more reliably correlated with the onset of ventriculitis in patients with in-situ EVDs, thus allowing for the optimal timing of CSF collection in these patients.
We feel confident that this study demonstrates no reliable CSF, serum, or clinical parameters that are effectively correlated with the development of ventriculitis in an EVD patient. As shown in
In conclusion, we found that the various CSF, serum, and clinical variables that we studied were not reliably correlated with the development of ventriculitis. In the future, we plan on carrying this study forward in a prospective manner to help us determine the optimal timing of CSF collection for patients with in-situ EVDs. At this time, the results from our study do not invalidate our departmental protocol of CSF collection in monitoring of ventriculitis. Thus, we will continue to draw CSF samples on patients with in-situ EVDs on our previously established schedule of Monday/Wednesday/Friday for as long as the EVD remains in place.
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