Hospital Infection Control

Meningitis

What are the key principles of preventing meningitis?

Nosocomial meningitis occurs following invasive procedures such as placement of ventricular catheters and craniotomy, following head trauma or in rare instances as the sequela of another primary infection. For the purpose of this document the term meningitis also encompasses ventriculitis.

The key principles for preventing nosocomial meningitis are related to the underlying mechanism for disease acquisition. Infections related to craniotomies can be decreased via employing surgical techniques that minimize cerebrospinal fluid (CSF) leakage, as well as limiting the total duration of surgery. Additionally, careful attention to cleansing the surgical site prior to surgery is important, as is employing hair clipping (not shaving), using chlorhexidine or iodine skin preparation, optimizing surgical draping and sterile field, and providing peri-procedure prophylactic antibiotics.

For meningitis related to internal ventricular catheter (IVC or CSF shunt) and external ventricular catheter (EVC) placement, adherence with careful aseptic technique is also essential. It is believed that infection related to these devices is often related to catheter contamination during surgery. One retrospective study revealed a decreased incidence of shunt infection following the adoption of a double-gloving strategy. It has also been suggested that even when a double-gloving strategy is employed that exchange of the outer pair of gloves prior to handling shunt material during surgery may further reduce infections.

For infections related to EVCs, the risk of infection may be related to the total amount of time the catheter is in place, although the temporal relationship between catheter presence and increased risk for infection is not known and is controversial. Some have advocated for regular EVC exchange, although there is some data that such a practice does not decrease infections. Risk factors for infection include intraventricular hemorrhage, CSF leakage, drain blockage and repeated CSF sampling.

There is evidence from a large meta-analysis supporting the use of prophylactic peri-procedural antibiotics during IVC placement in terms of reducing the risk for infection.

For dural invasive procedures such as diagnostic lumbar puncture and spinal anesthesia, careful aseptic technique, including the adoption of masks and surgical caps, is important. These infections are very rare (in the order of one in 50,000 procedures), and are thought to be predominantly related to contamination of the procedure site with the oral flora of the person performing the procedure.

External lumbar catheters are often used in the management of normal-pressure hydrocephalus. Risk factors for infections with these catheters include disconnecting the associated external drainage system. Things such as minimizing the time the catheter is in place and not routinely sampling CSF can lead to low rates of infection with these catheters.

In terms of meningitis related to head trauma, this most typically occurs when CSF leak occurs in the setting of basilar skull fracture. The routine use of prophylactic antibiotics in this setting was found not to be useful in one meta-analysis.

What are the conclusions of clinical trials and meta-analyses regarding the control of meningitis?

A meta-analysis of 15 randomized clinical trials encompassing 1,736 participants published in 2006 supports the use of peri-procedural prophylactic antibiotics with the placement of internal ventricular shunt devices. This same meta-analysis also found evidence of the benefit of antibiotic-impregnated catheters in reducing the risk of nosocomial meningitis. This analysis did not conclude that peri-procedural prophylactic antibiotics were useful for preventing infections related to external ventricular devices. However, only one relevant trial with a small number of patients was identified for this particular question.

A meta-analysis that included four randomized clinical trials with 208 participants published in 2006 found no benefit from the routine use of prophylactic antibiotics in patients with basilar skull fractures in terms of preventing meningitis.

A meta-analysis of six randomized clinical trials (involving 1,729 operations or patients of prophylactic antibiotics) in the setting of craniotomies revealed a significant reduction in the incidence of meningitis with their use (pooled OR = 0.43, 95% CI 0.20-0.92, p = 0.03).

What are the consequences of ignoring key concepts related to meningitis control?

If key concepts such as the employment of optimal aseptic technique for procedures that compromise central nervous system integrity are not employed then the incidence of nosocomial meningitis will most likely increase. If prophylactic antibiotics are used for longer than generally accepted durations then there is increased risk for the promotion of antibiotic resistant pathogens as well as for adverse drug events. For diagnostic lumbar puncture and related procedures (spinal and epidural anesthesia, et cetera) operators should employ sterile technique, including the use of face masks and operating caps. Failure to do so places their patients at higher risk for developing iatrogenic meningitis.

What other information supports the conclusions of meningitis studies, e.g., case-control studies and case series?

The incidence of meningitis following lumbar puncture and related procedures (spinal anesthesia, myelography, epidural anesthesia, pneumoencephalography, et cetera) is very low (occurring in approximately one in 50,000 procedures). In one literature review in the majority of cases operators failed to wear face masks and infections were primarily with streptococcal species, implicating contamination of the procedure with the operators' oral flora. Literature supports the use of double-gloving technique during the insertion of internal ventricular devices to help reduce infections. It is unclear if measures such as changing the external pair of gloves prior to handling shunt materials during surgery will decrease infections.

Summary of current controversies regarding meningitis prevention and control.

There is some controversy over whether or not peri-procedural antibiotics decrease the risk of developing meningitis following craniotomy. There is evidence from at least one meta-analysis that indicates that the risk for meningitis related to craniotomy procedures is reduced with the use of peri-procedural antibiotics.

There is also some debate about whether systemic antibiotic prophylaxis for internal ventricular catheter (IVC) and external ventricular catheter (EVC) placement are useful. Data from a 2006 meta-analysis support peri-procedural antibiotic prophylaxis in patients undergoing IVC placement although did not find support for EVCs (this latter conclusion was based on one randomized clinical trial that involved a small number of patients and may have been underpowered). The optimal duration of prophylactic antibiotic administration is uncertain. There is some evidence supporting the use of antibiotic-impregnated ventricular catheters in terms of preventing infection, however, further well-designed studies are needed to better answer this question.

For infections related to EVCs, the risk of infection may be related to the total amount of time the catheter is in place, although the temporal relationship between catheter presence and increased risk for infection is not known and is controversial. Some authors have advocated for regular EVC exchange, however data from at least one randomized clinical trial found no significant difference in the rates of EVC-related infections with this practice. Indeed, there is some concern that regular catheter exchange might actually increase infection risk.

Finally, it is unclear whether a strategy such as exchanging the outer pair of gloves during ventricular catheter placement prior to handling shunt materials will decrease risk for infection.

What is the impact of meningitis and the need for its control relative to other infections?

Rarely patients can develop nosocomial meningitis following systemic seeding from hospital-acquired bacteremia.

Summary of important clinical trials, meta-analyses, case control studies, case series, and individual case reports related to infection control and meningitis.

See Table I and Table II for a summary of important meningitis research.

Table I.

Key studies related to central nervous system invasive procedures and nosocomial meningitis
Reference Key question(s) Study information Key findings and implications
Ratilal, 2006 What is the utility of antibiotic prophylaxis for internal ventricular device (shunt) placement? Meta-analysis of 15 randomized clinical trials including 1,736 participants Antibiotic prophylaxis significantly decreased risk for shunt infection (OR = 0.52, 95% CI 0.36 to 0.74)
Barker 2007 Are prophylactic antibiotics effective for preventing meningitis following craniotomy? Meta-analysis of six randomized clinical trials encompassing 1,729 operations or patients There was a significant reduction in risk for meningitis when prophylactic antibiotics were used (pooled OR = 0.43, 95% CI 0.20 to 0.92, p = 0.03)
Ratilal, 2006 What is the utility of antibiotic-impregnated ventricular devices in terms of reducing the risk of infections? Meta-analysis of two randomized clinical trials including 398 participants Antibiotic impregnated catheters were useful in preventing shunt infections (OR = 0.21, 95% CI 0.08 to 0.55)
Yaniv, 2000 How common is meningitis following lumbar puncture? What are the risk factors for the development of infections? Case report and literature review; identified 60 cases of iatrogenic meningitis (not related to neurosurgical procedures) from 1979 to 1999 related to spinal anesthesia, myelography, diagnostic lumbar puncture, epidural anesthesia, pneumoencephalography, subarachnoid anesthesia and peribulbar anesthesia Meningitis following lumbar puncture and related procedures is a very rare eventFor cases in which these data were reported, the majority of operators did not wear face masks; streptococcal species were responsible for 33 of the 52 cases in which organisms were isolated (63%)
Baer, 2006 How common is meningitis following lumbar puncture? What are the risk factors for the development of infection? Case report and literature review; reviewed 179 cases of post-dural meningitis from 1952 to 2005 Post-dural puncture meningitis is a very rare eventAuthors suggest that the majority of cases of post-dural puncture meningitis are related to droplet contamination of procedure site with operator mouth organisms
Tulipan, 2006 What is the utility of a double-gloving strategy at the time of intraventricular device placement in terms of reducing infections? Retrospective (single center) study comparing incidence of intraventricular device infections for patients whose surgeons utilized single-layer gloving technique versus double-gloving technique that involved 863 patients Infection rate in the single-gloving group was 15.2% versus 6.7% in the double-gloving group (p = 0.0002)
Sørensen, 2008 To what extent do operator gloves become contaminated during intraventricular device insertion surgery? The outer gloves (double-gloving technique was employed) utilized during 10 intraventricular device placement operations were cultured In a large percentage of cases the gloves of the surgeons, assistants and scrub nurses were found to be contaminatedAuthors make the point that an intervention such as changing the outer pair of gloves prior to handling shunt materials during surgery may decrease rates of shunt infections
Mayhall, 1984 Does regular external ventricular drain change decrease the risk of infection? Prospective epidemiologic study that examined ventriculostomy-related infections in 172 consecutive patients (single center) Identified ventricular catheterization greater than 5 days as a risk factor for developing ventriculostomy-related infections (p = 0.017).Based on the above the authors recommended catheter removal and replacement for catheters required for greater than 5 days
Wong, 2002 Does regular external ventricular drain change decrease the risk of infection? Randomized controlled trial in two hospitals in Hong Kong involving 103 patients The CSF infection rate was 7.8% in the regular catheter change group versus 3.8% in the group where regular exchange did not occur (rate ratio = 1.80, 95% CI 0.33 to 9.81, p = 0.50)

Table II.

Key studies related to nosocomial meningitis not related to central nervous system procedures
Reference Key question Study information Key findings
Ratilal, 2006 What is the utility of antibiotic prophylaxis in patients with basilar skull fractures in terms of preventing meningitis? Meta-analysis of four randomized clinical trials involving 208 participants No significant differences between patients who received prophylaxis and those who did not were found for both all-cause mortality and the incidence of meningitis

Controversies in detail.

There is some debate about whether systemic antibiotic prophylaxis for internal ventricular catheter (IVC) and external ventricular catheter (EVC) placement are useful. Data from a meta-analysis published in 2006 supports peri-procedural antibiotic prophylaxis in patients undergoing IVC placement although did not find support for EVCs (this latter conclusion was based on one randomized clinical trial that involved a small number of patients and may have been underpowered).

There is some controversy over whether or not peri-procedural antibiotics decrease the risk of developing meningitis following craniotomy. For instance, one observational study involving 6,243 consecutive craniotomies from 1997 to 2003 found that antibiotic prophylaxis reduced incision site infections but did not prevent meningitis. In contrast, a meta-analysis of six randomized controlled trials involving 1,729 operations or patients demonstrated reduced risk for meningitis with the use of antibiotic prophylaxis for craniotomy (pooled OR = 0.43, 95% CI 0.20-0.92, p = 0.03).

For infections related to EVCs, the risk of infection may be related to the total amount of time the catheter is in place, although the temporal relationship between catheter presence and increased risk for infection is not known and is controversial. A prospective epidemiologic study by Mayhall and colleagues identified ventricular catheterization for greater than 5 days to be a risk factor for ventriculostomy-related infection (p = 0.017). A more recent randomized controlled study of patients with EVCs that compared the exchange of the device every 5 days versus no exchange found no significant difference in the rates of infections between the two groups (p = 0.50). There is some concern that the act of catheter change can, in and of itself, increase the risk for infection.

See Table III for more information.

Table III.

Summary of research regarding ventricular catheterization and infection
Reference Key Question Study Information Key Findings and Implications
Mayhall, 1984 Does regular external ventricular drain change decrease the risk of infection? Prospective epidemiologic study that examined ventriculostomy-related infections in 172 consecutive patients (single center) Identified ventricular catheterization greater than 5 days as a risk factor for developing ventriculostomy-related infections (p = 0.017). Based on this the authors recommended catheter removal and replacement for catheters required for greater than 5 days
Wong, 2002 Does regular external ventricular drain change decrease the risk of infection? Randomized controlled trial in two hospitals in Hong Kong. Patients with external ventricular devices were randomized to have regular catheter change every 5 days versus no regularly scheduled catheter change The CSF infection rate was 7.8% in the regular catheter change group versus 3.8% in the group where regular exchange did not occur (rate ratio = 1.80, 95% CI 0.33 to 9.81, p = 0.50)

The optimal duration of prophylactic antibiotic administration is uncertain. There is some evidence supporting the use of antibiotic-impregnated ventricular catheters in terms of preventing infection but further well-designed studies are needed to better answer this question. Finally, it is unclear whether a strategy such as exchanging the outer pair of gloves during ventricular catheter placement prior to handling shunt materials will decrease risk for infection.

What national and international meningitis guidelines exist?

The Infectious Diseases Society of America has a practice guideline for the management of bacterial meningitis in which infections related to ventricular catheters are mentioned. However, this document does not address issues related to the infection control aspects of nosocomial meningitis.

References

van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med 2010;362:146-54. PUBMED:20071704.

Tulipan N, Cleves MA. Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 2006;104:Suppl:S5-S8. PUBMED:16509473.

Sørensen P, Ejlertsen T, Aaen D, Poulsen K. Bacterial contamination of surgeon's gloves during shunt insertion: a pilot study. Br J Neurosurg 2008;22:675-7. PUBMED:19016119.

Mayhall CG, Archer NH, Lamb VA, et al. Ventriculostomy-related infections: a prospective epidemiologic study. N Engl J Med 1984;310:553-9. PUBMED:6694707.

Wong GK, Poon WS, Wai S, Yu LM, Lyon D, Lam JM. Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2002;73:759-61. PUBMED:12438486.

Ratilal BO, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 2006;3:CD005365. PUBMED:16856095.

Baer ET. Post-dural puncture bacterial meningitis. Anesthesiology 2006;105:381-93. PUBMED:16871073.

Governale LS, Fein N, Logsdon J, Black PM. Techniques and complications of external lumbar drainage for normal pressure hydrocephalus. Neurosurgery 2008;63:Suppl 2:379-84. PUBMED:18981847.

Ratilal BO, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2006;1:CD004884. PUBMED:16437502.

Blomstedt GC. Results of trimethoprim-sulfamethoxazole prophylaxis in ventriculostomy and shunting procedures. A double-blind randomized trial. J Neurosurg 1985;62:694-7. PUBMED:3886851.

Barker FG. Efficacy of prophylactic antibiotics against meningitis after craniotomy: a meta-analysis. Neurosurgery 2007;60:887-94. PUBMED:17460524.

Yaniv LG, Potasman I. Iatrogenic meningitis: an increasing role for resistant viridans streptococci? Case report and review of the last 20 years. Scand J Infect Dis 2000;32:693-6. PUBMED:11200384.

Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 2001;94:195-201. PUBMED:11213954.

Korinek AM, Baugnon T, Golmard JL, van Effenterre R, Coriat P, Puybasset L. Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurgery 2008;62 Suppl 2:532-9. PUBMED:18596451.

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39:1267-84. PUBMED:15494903.

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