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Case 4 complicated hospital acquired infection

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headache, weakness, visual disturbance, ataxia ... coliform in urine. GNB seen in blood cultures. Imp Septic shock. ciprofloxacin ... – PowerPoint PPT presentation

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Title: Case 4 complicated hospital acquired infection


1
Case 4 complicated hospital acquired infection
  • Dr Nick Brown
  • Addenbrookes Hospital
  • Cambridge, UK

5 June 2008 RCP (London)
2
Case
  • 56 y lady
  • headache, weakness, visual disturbance, ataxia
  • left parieto-occipital craniotomy with excision
    of parasagital meningioma
  • Day 1 Well, mobilising
  • Day 2 raised wbc 26.5 x 109/L noted ?why

3
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4
Case
  • Day 3 dysphasic, hypotensive, oliguric
  • coliform in urine
  • GNB seen in blood cultures
  • Imp Septic shock
  • ciprofloxacin
  • cefotaxime plus metronidazole

5
Infection following neurosurgery
  • Procedure Risk index n rate
  • craniotomy 0 4,717 0.9
  • 1 14,864 1.7
  • 2, 3 4,666 2.4
  • other nervous system 0, 1, 2, 3 2,356 1.5
  • ventricular shunt 0 4,208 4.4
  • 1, 2, 3 12,324 5.4

CDC NNIS system report Am J Infect Control 2004
32 470-85
6
Neurosurgical site infection
  • Prospective study in 10 hospitals 1993-1994
  • craniotomy (elective or emergency)
  • risk factor categorisation
  • follow-up 30 days
  • evaluation for surgical site infection
  • assessment of relative risk factors

Korinek et al. Neurosurgery 1997 41 1073-9
7
Results
  • 2,944 patients

Elective 2,284 (78) Emergency 660 (22)
Clean 2,578 (88) Clean / contaminated
234 (8) Contaminated 40 (1) Dirty 84 (3)
Tumour 1,380 (47) Vascular 535
(18) Neurotrauma 532 (18) Infection 58
(2) Biopsy 254 (9) Other 185 (6)
Korinek et al. Neurosurgery 1997 41 1073-9
8
Organisms isolated from 117 infections in 2,944
patients (4)
  • Scalp Bone flap
    Meningitis/abscess Total
  • MRSA 5 0 12 17 (18)
  • MSSA 7 8 17 32 (33)
  • S. epidermidis 1 0 3 4 (4)
  • streptococci 2 0 4 6 (6)
  • other Gram cocci 1 0 4 5 (5)
  • Enterobacteriaceae S 0 0 4 4 (4)
  • Enterobacteriaceae R 2 0 11 13 (13)
  • Acinetobacter sp. 5 1 2 8 (8)
  • P. aeruginosa 1 0 2 3 (3)
  • others 1 0 3 4 (4)
  • Total 25 9 62 96

Korinek et al. Neurosurgery 1997 41 1073-9
9
Risk factors for deep infection
  • CSF leakage
  • external drainage
  • true CSF leak
  • early subsequent operation

Korinek et al. Neurosurgery 1997 41 1073-9
10
Case
  • Day 4 persistent fever (off filter)
  • hypotension
  • GNB from head wound swab
  • ? Intra-cranial infection
  • vancomycin plus carbapenem

11
Temperature
surgery
12
Case
  • Day 5 Sensitive E. coli confirmed from blood
    and urine
  • Continued carbapenem alone
  • Day 6-13 Slow progress
  • Day 14 head has expanded and is leaking clear
    fluid from the wound

13
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14
galea aponeurotica (epicranial aponeurosis)
15
Problems with the diagnosis of infection
following neurosurgery
  • Clinical signs
  • steroids
  • fever
  • CSF
  • other laboratory parameters
  • extra-cranial infection

16
Diagnosis of bacterial meningitis
post-neurosurgery
  • Useful criteria Less helpful criteria
  • high fever CSF glucose
  • new neurological deficit CSF protein
  • active CSF leak type of operation
  • CSF leukocytosis presence of foreign material
  • blood leukocytosis steroid use
  • altered mental status
  • neck stiffness
  • headache / nausea

Ross et al. Journal of Neurosurgery 1988 69
669-74
17
Total white cell count and C-reactive protein
surgery
18
Case
  • Day 26 Seizures
  • Day 30 Head wound swab
  • Pseudomonas aeruginosa isolated
  • Day 36 Surgery for debridement and drainage of
    subgaleal collection
  • Cultures sterile
  • Subsequently improved but left with neurological
    deficit

19
In vitro activity of carbapenems against
non-fermentative Gram negative bacteria
Jones RN et al. J Antimicrob Chemother 2004 54
144-154
20
Neurotoxicity of carbapenems
  • risk factors
  • history of seizures
  • underlying CNS disease
  • age
  • renal failure
  • high dose
  • Incidence
  • imipenem 15 / 1,723 (0.9)
  • meropenem 4 / 4,748 (0.08)
  • ertapenem 3 / 1,954 (0.15)

Wang et al. Rev Infect Dis 1985 7 (Suppl 3)
s528-s536 Norrby et al. Scand J Infect Dis 1999
31 1-8 Teppler et al. J Antimicrob Chemother
2004 53 Suppl 2 ii75-ii81
21
Imipenem in acute meningitis
  • 21 children (age 3 months - 4 years)
  • delayed sterilisation of CSF in 2 (both H.
    influenzae)
  • 7 had seizures (33)
  • Study terminated early

Wong et al. Pediatr Infect Dis J 1991 10 122-5
22
Summary
  • Infection following neurosurgery or head injury
    is uncommon, but diagnosis may be difficult
  • Antibiotic-resistant Gram negative bacilli
    account for a significant proportion of
    infections
  • Imipenem and ertapenem are relatively
    contraindicated in this setting.
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