Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.
Clin Microbiol Infect. 2017 Sep;23(9):621-628. doi: 10.1016/j.cmi.2017.05.013. Epub 2017 May 18.
Infections complicating neurosurgery pose unacceptable mortality and morbidity.
To summarize what is known about the epidemiology, diagnosis and treatment of post-neurosurgical meningitis (PNM).
PubMed, references of identified studies and reviews, and personal experience when evidence was lacking.
The incidence and pathogen distribution of PNM is highly variable. A shift towards Gram-negative bacteria has been observed with use of antibiotic prophylaxis and antibiotic-coated devices directed mainly against Gram-positive bacteria. However, knowledge of the local epidemiology is necessary to treat PNM. The diagnosis of PNM is difficult because, unlike community-acquired meningitis, symptoms are less specific; patients are ill at baseline and many neurosurgical conditions mimic meningitis and cause cerebrospinal fluid (CSF) abnormalities. Pivotal CSF findings for diagnosis of PNM are the CSF glucose, CSF lactate and Gram stain. CSF leucocyte counts are not specific in PNM. Current diagnostic capabilities leave a non-negligible category of patients with microbiologically negative, uncertain diagnosis of PNM. There is no high-quality evidence on several cardinal issues in PNM management, including the effectiveness of intraventricular or intrathecal (IV/IT) antibiotics, effectiveness of dual antibiotic therapy for multidrug-resistant Gram-negative bacteria; clinical benefit of routine therapeutic drug monitoring; and safest timing of shunt replacement. Some data point to a potential benefit of IV/IT antibiotic treatment, mainly for PNM caused by carbapenem-resistant Gram-negative bacteria. Carbapenem-colistin combination therapy is suggested for PNM caused by carbapenem-resistant Gram-negative bacteria with a carbapenem MIC ≤8 mg/L.
Guiding the optimal management of PNM will necessitate collaborative multicentre efforts and unique study designs.
神经外科术后感染会导致不可接受的死亡率和发病率。
总结神经外科术后脑膜炎（PNM）的流行病学、诊断和治疗。
PubMed、已确定研究和综述的参考文献，以及缺乏证据时的个人经验。
PNM 的发病率和病原体分布差异很大。随着抗生素预防和主要针对革兰阳性菌的抗生素涂层器械的使用，革兰阴性菌的比例有所增加。然而，了解当地的流行病学情况对于治疗 PNM 是必要的。PNM 的诊断较为困难，因为与社区获得性脑膜炎不同，其症状不那么具有特异性；患者在发病前就已处于患病状态，许多神经外科疾病会模仿脑膜炎并导致脑脊液（CSF）异常。诊断 PNM 的关键 CSF 发现是 CSF 葡萄糖、CSF 乳酸和革兰氏染色。CSF 白细胞计数在 PNM 中不具有特异性。目前的诊断能力使得相当一部分微生物学阴性、PNM 诊断不确定的患者无法明确诊断。在 PNM 管理的几个关键问题上，包括脑室或鞘内（IV/IT）抗生素的有效性、针对多药耐药革兰氏阴性菌的双联抗生素治疗的有效性、常规治疗药物监测的临床获益以及分流器更换的最佳时间，都没有高质量的证据。一些数据表明 IV/IT 抗生素治疗可能有潜在益处，主要针对碳青霉烯类耐药革兰氏阴性菌引起的 PNM。对于碳青霉烯 MIC≤8mg/L 的碳青霉烯类耐药革兰氏阴性菌引起的 PNM，建议使用碳青霉烯-黏菌素联合治疗。
指导 PNM 的最佳管理将需要协作的多中心努力和独特的研究设计。
