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Infections in Neurosurgery

Infections in Neurosurgery. AIKATERINI PANTELI NEUROSURGEON YEDITEPE UNIVERSITY DEPARTMENT OF NEUROSURGERY. Antibiotics for neurosurgery. Oral penicillins Superficial staphylococcal infections (e.g amoxycillin + clavulanic acid ) Cephalosporines 1 st and 3 rd generation Vancomycin

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Infections in Neurosurgery

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  1. Infections in Neurosurgery AIKATERINI PANTELI NEUROSURGEON YEDITEPE UNIVERSITY DEPARTMENT OF NEUROSURGERY

  2. Antibiotics for neurosurgery • Oral penicillins • Superficial staphylococcal infections • (e.g amoxycillin + clavulanic acid ) • Cephalosporines • 1st and 3rd generation • Vancomycin • Chloramphenicol • (excellent CSF penetration)

  3. Prophylaxis principles • antibiotics must be in tissues at time of contamination (give 60 minutes prior to incision) • repeated administration vital in prolonged procedures • typical infecting organisms are usually predictable. Coverage for these organisms is adequate

  4. Wound InfectionsRisk Factors • General • Malnourishment • Anaemia • Coexisting infection • Immunocompromised patients • Diabetes mellitus

  5. Wound InfectionsRisk Factors • Local • Foreign bodies • Wound drains • Haematoma formation • CSF leakage • Reoperation

  6. Post-op wound infections • 1-4% • Erythema, oedema, pain, purulent discharge • Patient may be febrile • Antibiotics (broad spectrum) • Complications: • Meningitis • Osteomyelitis • Abcess (epi/subdural, brain)

  7. Osteomyelitis of the skull • Due to prolonged contact of the bone flap to purulent material in the subgaleal or epidural space • Plain X-rays, CT

  8. Postop superficial spinal infection • Rate depends on the presence or absence of instrumentation • Erythema, pain, purulent discharge • Complication : extension to the deep surgical site

  9. Wound infections • After spinal surgery-laminectomy etc. • Culture • Vancomycine+3.gen cephalosporin • Change after cuture results • Debridement • Osteomyelitis of the skull • Remove the bone flap • Staphylococci is most common • Antibiotics (vancomycin+3. gen. Cephalosporins)

  10. Shunt infection • Rate of infection 3-20% • Risk factors • Young age • Length of procedure • Open neuraltube defect • Pathogens: Staph epidermidis, S. Aureus, gr (-) bacilli • Presentation: fever and headache, abdominal signs…

  11. Treatment • Remove the shunt • i.v vancomycin • Rifampin may be included • Change the treatment after results of culture • İntrathecal treatment

  12. Meningitis • Prodrome of fever, headache are benign until altered consciousness, focal neurologic deficits or seizures appear. • Community- acquired • Post-traumatic • Post- neurosurgical • Recurrent

  13. Approach to the patient: • Nuchal rigidity is the pathognomonic sign of meningeal irritation. • Kernigs’ sign • Brudzinski’s sign • Failure of a patient suspected with viral encephalitis to improve should prompt reevaluation.

  14. Bacterial meningitis • Bacterial meningitis is an acute purulent infection within the subarachnoid space. • Bacterial meningitis may result to decreased consciousness, seizures, raised ICP and stroke. • Meningoencephalitis – the parenchyma, meninges and subarachnoid suffer

  15. Bacterial meningitis is the most common form of suppurative CNS infection. • S. pneumoniae is the most common cause in adults >20 • N. meningitides is common in ages 2-20 with petechial and purpuric lesions. • Group B or S. agalactiaepredominates in neonates and elderly >50 • Listeria predominates in neonates and pregnant women due to organisms in ready to eat foods • H. influenzae in unvaccinated children • Staph aureusare causes of infection following an invasive neurosurgical procedure

  16. Pathophysiology: • Bacteria are able to avoid phagocytosis because of a polysaccharide capsule. • A critical event in the pathogenesis of bacterial meningitis is the inflammatory reaction induced by the invading bacteria.

  17. Pathophysiology • Lysis of bacteria with the subsequent release of cell wall components into the subarachnoid space • Cytokine response is followed by an increase in CSF protein concentration and leukocytosis. • Much of the pathophysiology of bacterial meningitis is a direct consequence of elevated levels of CSF cytokines and chemokines. • TNF and IL1 act synergistically to increase the permeability of the blood brain barrier resulting in vasogenic edema and the leakage of serum proteins into the subarachnoid space.

  18. Pathophysiology • During the very early stages of meningitis there is an increase in cerebral blood flow followed by a decrease in blood flow and loss of cerebrovascular autoregulation. • Combination of cytotoxic, vasogenic and interstitial edema lead to increased ICP and coma.

  19. Clinical presentation: • Clinical triad of meningitis: fever, headache and nuchal rigidity. • Focal seizures may be due to focal arterial ischemia, infarction, and cortical venous thrombosis with hemorrhage or focal edema. • Generalized seizures or status epilepticus may be due to hyponatremia and cerebral anoxia. • Raised ICP is an expected complication and is the major cause of obtundation and coma.

  20. Signs of increased ICP are • papilledema, dilated poorly reactive pupils, 6th nerve palsie, decerebrate posturing and Cushing’s reflex (bradycardia, hypertension, irregular respirations) • Most disastrous complication is cerebral herniation.

  21. Diagnosis: • Examination of CSF • Classic CSF abnormalities: • leukocytosis (>100 cells) • decreased glucose <2.2 mmol/L or serum glucose of <0.4 • increased protein concentration >0.45 g/L • increased opening pressure >180 mmH2O

  22. Tests • CSF latex agglutination test has a specificity of 95-100% for S. pneumoniae and N. meningitides, so a (+) test is virtually diagnostic of bacterial meningitis. • Limulus amoebocyte lysate assay is a rapid diagnostic test for the detection of gram (–) endotoxin in CSF

  23. Radiology • MRI is preferred than CT because of its superiority in demonstrating areas of cerebral edema and ischemia.

  24. Differential diagnosis: • findings on CSF studies, neuroimaging and EEG distinguishes HSV encephalitis from bacterial meningitis • Viral CSF infections: • lymphocytic pleocytosis with a normal glucose • Bacterial: • PMN pleocytosis and hypoglycorrhachia

  25. Subacutely evolving meningitis • May on occasion be considered as differential diagnosis of acute meningitis. • Principal causes include M. tuberculosis, C. neoformans, H. capsulatum, C. immitis and T. pallidum

  26. Treatment • Treatment: bacterial meningitis is a medical emergency. • Goal is to begin antibiotic therapy within 60 min.

  27. In meningitis following neurosurgical procedures: • vancomycin and ceftazidime • Ceftazidime is the only cephalosporin with adequate activity against CNS infections with P. aeruginosa.

  28. Treatment • Meropenem is a carbapenem antibiotic that is highly active in vitro against Listeria, P. aeruginosa and penicillin resistant pneumococci. • Meningococcal meningitis: Pen G, if resistant Ceftriaxone. Chemoprophylaxis with Rifampicin. Rifampicin is CI in pregnant. • Pneumococcal meningitis: cephalosporin + vancomycin, MICs > 0.5 ug/mL treat with cefotaxime or ceftriaxone, MICs of >1 ug/mL vancomycin • Patients with penicillin and cephalosporin resistant strains of S. pneumoniae who don’t respond to vancomycin may be given intraventricular vancomycin • L. monocytogenes meningitis: ampicillin/ gentamicin. In penicillin allergic patients give cotrimoxazole • Staphylococcal meningitis: nafcillin, for MRSA use vancomycin • Gram – bacillary meningitis: 3rd gen cephalosporins but with P. aeruginosa use ceftazidime

  29. Adjunctive therapy • Dexamethasone • For increased ICP: elevate head to 30-45 degrees, intubation, hyperventilation and mannitol.

  30. Viral • Acute Viral Meningitis: fever, headache and meningeal irritation accompanied by arthralgia, malaise and anorexia. • Photophobia and pain on moving the eyes. • Kernig’s and brudzinski’s sign are absent. • Enteroviruses account for 75-90% of aseptic meningitis. • HSV1 : most common sporadic cause • Immunocompromised : HIV CMV • Laboratory Diagnosis of CSF: • Lymphocytic pleocytosis and slightly elevated protein concentration with normal glucose. • PCR – diagnostic procedure of choice • HSV PCR- for recurrent episodes of aseptic meningitis • Oligoclonal bands can also be found in noninfectious neurologic diseases. • Enterovirus infection can have exanthema, foot and mouth disease, herpangina, pleurodynia, myopericarditis and hemorrhagic conjunctivitis ( stigmata of enterovirus infection)

  31. Post traumatic meningitis • 1-20% after moderate-severe trauma • Within 2 weeks after trauma • 75% have skull base fracture • Pathogens: nasal cavity: Gr (+) cocci and Gr (– ) bacilli • Staph hemolyticus,Strep pneumonia • E. coli, Klebsiella Pneumonia

  32. Treatment • Surgical+ antibiotic • İmipenem and ciprofloxacin+ vancomycin

  33. Epidural / Subdural empyema • Supurative infection that occurs in the subdural space • Trauma, thromboflebitis, sinusitis or extension of local infection to the epi/subdural space or both • May progress rapidly!!

  34. Presentation • Fever • Headache • Meningismus • Seizures • CT or MRI is very helpful in diagnosis

  35. Treatment • Surgical drainage • Antibiotics: like cerebral abcess

  36. Cerebral abcess • Risk factors: • Pulmonary abnormalities:infection, AV fistula • Congenital cyanotic heart disease: TOF • Endocarditis • AIDS • Penetrating head trauma • Sinusitis, ent infections

  37. Pathogens • Streptococcus is the most frequent • Anaerobes like Bacteroides • May be multiple

  38. Presentation • Increased intracranial pressure • Diagnosed by MRI or CT • WBC, CRP, Blood cultures, ESR

  39. MRI findings • Imaging varies with stage of abscess development • Early capsule: Well-defined, thin-walled enhancing rim • Ring-enhancing lesion with high signal • T2 hypointense abscess rim with surrounding edema • Typically supratentorial • Frontal and parietal lobes most common, gray-white junction (hematogenous)

  40. Treatment • Surgical drainage • Antibiotics: vancomycine+ 3 gen.cephalosporins + metronidazol or chloramphenicol • Long term treatment by i.v antibiotics for 6-8 weeks followed by oral antibiotics for 4-8 weeks

  41. VENTRICULITIS

  42. Ventriculitis • Ventricular ependyma infection related to meningitis,ruptured brain abscess, or ventricular catheter • Common bacterial organisms: Staphylococcus, streptococcus, enterobacter • Ventriculomegaly with debris level, enhancing ependyma, periventricular T2 hyperintensity • Mortality rate 40-80%!! • Treat underlying organism, drain/intrathecal antibiotics.

  43. Hydatid cyst • Echinococcosis granulosis is a dog tapeworm • Endemic disease and dogs are the hosts • Sheep and man are the intermediate hosts • Presentation is by signs of intracranial pressure • Treatment is surgical evacuation • Antibiotic treatment is albendazole

  44. Fungal infections • Candidiasis is the most common • Most common in immunocompromised patients • Treatment: antifungal agents: fluconazole, amphotericin B

  45. Spinal infections • Vertebral osteomyelitis • Discitis • Epidural abcess • Subdural empyema • Meningitis • Spinal cord abcess

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