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Internal Medicine

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A 30-year-old male with a history of obstructive hydrocephalus had implantation of a ventriculoperitoneal shunt. Three months after implantation, he developed headache and nausea over a period of about one week; he denied fever. On physical examination, he was afebrile with normal vital signs. He was awake, but somewhat lethargic.

There was no tenderness or erythema along the area of the implanted shunt. His abdominal examination was normal. Neurosurgery is consulted and cerebrospinal fluid removed from the shunt reveals a WBC count of 500/mm3 with 80% segs, glucose of 45 mg/dL, and protein of 50 mg/dL. Gram stain was negative, but cultures grew Staphylococcus epidermidis.

In addition to administration of intravenous vancomycin, which of the following is the most appropriate management of this patient?

  • Intraventricular vancomycin through the implanted shunt

  • Shunt removal and immediate implantation of a new shunt

  • Shunt removal, external drainage, and re-shunt after - cx

  • Add oral rifampin to intravenous vancomycin

This patient has a cerebrospinal fluid (CSF) shunt infection. Staphylococci are the most likely infecting agents (55-95% of cases), with most caused by coagulase-negative staphylococci. The most common clinical symptoms are headache, nausea, lethargy and altered mental status; fever is reported in 14-92% of cases.

Numerous methods of treating CSF shunt infections have been reported, but no randomized, prospective trials have been performed. The principles of antimicrobial therapy are generally the same as for acute bacterial meningitis. Direct instillation of antimicrobial agents into the ventricles (i.e., through an external ventriculostomy or shunt reservoir) is occasionally needed for difficult to eradicate infections, but the indications for intraventricular administration are not well-defined.

Attempts to treat Staph epidermidis CSF shunt infections with use of systemic antimicrobial agents alone (given by the intravenous and/or intraventricular route) rarely have been successful.

Combining removal of shunt hardware with immediate shunt replacement and intravenous antimicrobial therapy cures approximately 65-75% of patients.

Antimicrobial use with removal of all components of the shunt along with some component of external drainage appears to be the most effective treatment, with treatment success usually >85%. @Everyone

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