Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana.
Neurosurg Focus. 2017 Nov;43(5):E8. doi: 10.3171/2017.8.FOCUS17443.
OBJECTIVE Neurosurgical infections due to multidrug-resistant organisms have become a nightmare that neurosurgeons are facing in the 21st century. This is the dawn of the so-called postantibiotic era. There is an urgent need to review and evaluate ways to reduce the high mortality rates due to these infections. The present study evaluates the efficacy of combined intravenous plus intrathecal or intraventricular (IV + IT) therapy versus only intravenous (IV) therapy in treating postneurosurgical Acinetobacter baumannii infections. METHODS The authors performed a meta-analysis of all peer-reviewed studies from the PubMed, Cochrane Library database, ScienceDirect, and EMBASE in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Five studies were finally included in the present analysis: 126 patients were studied who had postneurosurgical A. baumannii infection. The Cochrane collaboration tool was used to evaluate risk of bias, and a test of heterogeneity was performed. The I statistic was calculated. The patients were divided into 2 groups: the IV group received only intravenous therapy and the IV + IT group received both intravenous and intrathecal or intraventricular antimicrobial therapy. The outcome was mortality attributed specifically to A. baumannii infection in postneurosurgical cases. The pooled data were analyzed using the Cochran-Mantel-Haenszel method in a fixed-effects model. RESULTS The total number of patients in the IV-only group was 73, and the number of patients in the IV + IT group was 53. The mean duration of intravenous therapy was 27 days. The mean duration of intrathecal colistin was 21 days. The intravenous dose of colistin ranged from 3.75 to 8.8 MIU per day. The dose of intrathecal colistin ranged between 125,000 and 250,000 IU per day. The overall calculated odds ratio for mortality for the IV + IT group after pooling the data was 0.16 (95% CI 0.06-0.40, p < 0.0001). The patients who received IV + IT therapy had an 84% lower risk of dying due to the infection compared with those who received only IV therapy. CONCLUSIONS There is an 84% lower risk of mortality in patients who have been treated with combined intrathecal or intraventricular plus intravenous antimicrobial therapy versus those who have been treated with intravenous therapy alone. The intrathecal or intraventricular route should be strongly considered when dealing with postneurosurgical multidrug-resistant A. baumannii infections.
由于多药耐药菌引起的神经外科感染，已成为 21 世纪神经外科医生面临的噩梦。这是所谓的后抗生素时代的黎明。迫切需要审查和评估降低这些感染高死亡率的方法。本研究评估了静脉联合鞘内或脑室内（IV + IT）治疗与单纯静脉（IV）治疗在治疗神经外科术后鲍曼不动杆菌感染中的疗效。
作者根据 PRISMA（系统评价和荟萃分析的首选报告项目）指南，对来自 PubMed、Cochrane 图书馆数据库、ScienceDirect 和 EMBASE 的所有同行评审研究进行了荟萃分析。最终有 5 项研究纳入本分析：共研究了 126 例神经外科术后鲍曼不动杆菌感染患者。使用 Cochrane 协作工具评估偏倚风险，并进行了异质性检验。计算了 I 统计量。患者分为 2 组：IV 组仅接受静脉治疗，IV + IT 组接受静脉和鞘内或脑室内抗菌治疗。结果是神经外科术后特定归因于鲍曼不动杆菌感染的死亡率。使用 Cochran-Mantel-Haenszel 方法在固定效应模型中分析汇总数据。
IV 组仅接受静脉治疗的患者总数为 73 例，IV + IT 组患者总数为 53 例。静脉治疗的平均持续时间为 27 天。鞘内多粘菌素的平均持续时间为 21 天。多粘菌素的静脉剂量范围为每天 3.75 至 8.8MIU。鞘内多粘菌素的剂量范围为每天 125,000 至 250,000IU。汇总数据后，IV + IT 组的总体死亡率计算优势比为 0.16（95%CI 0.06-0.40，p<0.0001）。与仅接受静脉治疗的患者相比，接受 IV + IT 治疗的患者死于感染的风险降低了 84%。
与单纯静脉治疗相比，接受鞘内或脑室内联合静脉抗菌治疗的患者的死亡率降低了 84%。在处理神经外科术后多药耐药鲍曼不动杆菌感染时，应强烈考虑鞘内或脑室内途径。
