Sequential Intravenous-Oral Therapy for Pediatric Streptococcus anginosus Intracranial Infections

Introduction Streptococcus anginosus group is a common cause of pediatric intracranial infections but treatment recommendations, including use of oral therapy, are poorly defined. Methods We performed a retrospective review from 2004-2019 of all patients with Streptococcus anginosus group pyogenic intracranial infections at Children’s Hospital Colorado, highlighting patients transitioned to oral therapy. The primary endpoint was worsening infection necessitating intravenous antibiotics or a source control procedure after transition to oral therapy. Results Of 107 patients with Streptococcus anginosus intracranial infections, 61 were transitioned to exclusive oral therapy after a median intravenous duration of 37 days, overwhelmingly with a levofloxacin-based regimen. Only one failure was noted in a patient who did not fill their prescription. Patients with epidural infections were more likely to be transitioned to oral therapy within the first 28 days of treatment (defined as “early”). Patients with parenchymal infections, bacteremia, co-pathogens, higher inflammatory markers, and requiring >1 source control procedure were less likely to be transitioned early to oral therapy. Complications of a central catheter and/or intravenous medications contributed to 56% of oral transitions. Conclusions Levofloxacin-based oral regimens were effective and well-tolerated. Patients with less severe infections were more likely to be transitioned early to oral therapy. Criteria for transitioning patients to oral antibiotics for intracranial infections should be established to minimize risks inherent with central catheters.

Clinical Efficacy and Safety of Neuroendoscopic Surgery for Severe Ventricular Thalamic Hemorrhage

Objective To summarize and analyze the clinical efficacy and safety of neuroendoscopic surgery in the treatment of patients with severe ventricular thalamic hemorrhage. Methods Eight-three patients with severe ventricular thalamic hemorrhage were treated in the Neurosurgery Department of Anqing Hospital Affiliated to Anhui Medical University from July 2019 to August 2021. Of the 83 patients, 41 underwent neuroendoscopic surgery and 42 underwent simple extraventricular drainage. The hospital stay, GCS scores on the 1st and 14th days postoperatively, the incidence of intracranial infections, and the clearance of postoperative hematomas were compared and analyzed between the two groups. The patients were followed up to 6 months. The prognosis was evaluated by the activity of daily living (ADL) score. A head CT or MRI was obtained to determine whether there was hydrocephalus, cerebral infarction, or other related complications. Results The postoperative hospital stay was 17.42±1.53 days, the GCS score was 6.56±0.21 points on day 1 and 10.83±0.36 points on day 14, intracranial infections occurred in three patients (7.31%) and the hematoma clearance rate was 83.6±5.18% in the neuroendoscopy group, all of which were significantly better than the simple extraventricular drainage group (P < 0.05). After 6 months of follow-up, 28 patients (68.29%) had a good prognosis, 5 patients (12.19%) died, and 4 patients(9.75%)had hydrocephalus in the neuroendoscopy group. In the extraventricular drainage group, the prognosis was good in 15 patients (35.71%), death in 12 patients (28.57%), and hydrocephalus in 17 patients (40.47%). The follow-up results showed that the good prognosis, mortality, and incidence of hydrocephalus in the neuroendoscopy group were significantly better than the extraventricular drainage group (P < 0.05). Conclusion Compared with traditional ventricular-puncture drainage, simultaneous endoscopic sinus surgery for severe ventricular thalamic hemorrhage had a higher hematoma clearance rate, fewer intracranial infections, and hydrocephalus, which together improve the clinical prognosis, and is thus recommended for clinical use.

Intracranial Infection Caused by Multidrug-resistant Acinetobacter Baumannii

Objective: To report the successful treatment of a patient who underwent vestibular schwannoma resection and developed intracranial infection caused by multidrug-resistant Acinetobacter baumannii (MRAB), and to review the recent relevant literature. Methods: The patient was diagnosed with MRAB infection based on clinical manifestations and cerebrospinal fluid (CSF) culture. The treatment included external ventricular drainage, posterior fossa decompressive craniectomy, and endoscopic lavage for fourth ventricle, subdural drainage, and intravenous injection /ventricular irrigation of sulperazone. Results: The MRAB-induced intracranial infection was successfully cured. The follow-up lasted for 84 months, and the patient has resumed normal life and work. Conclusion: Active individualized treatment should be administered at the earliest. The drainage of CSF, ventricular lavage, and proper choice of antibiotics are key to treat intracranial infections caused by MRAB.

1161. Increasing incidence of Sinogenic Intracranial Infections in Utah Children 2004-2019

Background Intracranial extension of sinusitis is a rare complication. Non-specific presentations are a diagnostic challenge, and complications include long-term neurologic sequelae. Early recognition is critical, although optimal management remains poorly characterized. Methods We conducted a retrospective chart review of 123 patients admitted to Primary Children’s Hospital between 2004-2019 with ICD9 and ICD10 codes for sinusitis and intracranial suppurative infection. Chart review confirmed cases in patients &lt; 18 years with evidence of sinusitis and intracranial extension. Variables collected included: demographic data, clinical presentation, microbial profile, clinical management, and outcomes. Results We observed 84 pediatric sinogenic intracranial infections between 2004-2019. Incidence significantly increased over the interval. Median patient age was 12.8 years (IQR 10.5-14.7 years); most were male (n=52). The most common presenting symptoms were headache and fever. Most patients (n=80) required surgical management; 62 required neurosurgery. All but one patient survived. Most infections were polymicrobial (n=47). Streptococcus anginous group were most frequently identified (n=32). All patients were started on vancomycin empirically; only 10 required use for definitive management. Most patients were treated with a carbapenem (n=42) or ceftriaxone plus metronidazole (n=32). Average duration of antibiotics was 44 days (IQR 38-55 days). The most common complication was epilepsy (n=11). Patients with Streptococcus sp. infections were more likely to experience adverse outcomes (p= 0.04). We observed significantly decreased carbapenem use following introduction of an antimicrobial stewardship program in 2012, with no change in clinical outcomes. Annual incidence of Sinogenic Intracranial Infections Shown is the increasing incidence of sinogenic intracranial infections annually in the state of Utah/100,000 children. Conclusion Sinogenic intracranial infections are increasingly frequent severe pediatric infections with associated long term neurologic sequelae. Most patients require both surgical and long-term IV antibiotic treatment. Most infections are polymicrobial. Streptococcus sp. are commonly identified. Antibiotic resistant bacteria are rare. The combination ceftriaxone and metronidazole is appropriate for treatment of most infections. Disclosures Anne Bonkowsky, MD/PhD, BioFire Diagnostics (Consultant, Grant/Research Support, Other Financial or Material Support, I have intellectual property through the University of Utah in BioFire Diagnostics and the FilmArray and receive royalties through the University of Utah.)Merck (Advisor or Review Panel member)

Prevalence and Associated Factors of Malnutrition in Patients with Intracranial Infections at Sanglah Hospital Denpasar

Malnutrition is a major health problem in developing countries, it can occur acutely, chronically or combination of both. Malnutrition aggravates the condition of infectious diseases, including intracranial infections. Hereby we aimed to determine the prevalence and factors associated with malnutrition in pediatric patients with intracranial infections in Sanglah Central General Hospital. This cross-sectional analytic study was conducted in patients with final diagnosis intracranial infection whom were treated from January 2019 to March 2021. The study was conducted in pediatric patients aged 1 month-18 years old and patient would be excluded if had any of these conditions: 1) incomplete medical records, 2) discharge by his/her own request, 3) hydrocephalus for which VP shunt had not been performed, 4) diagnosis of tumor or mass that could affect body weight measurement. Secondary data such as weight/height for children <5 years and BMI/age for children >5 years were measured in growth curve by using the WHO Anthro application. Total samples were 83 children with predominance age group was 0-5 years old. Malnutrition was found in 48.1% patients. Chronic malnutrition was more common than acute malnutrition (32.5% vs. 31.3%). Age below 5 years has relationship with the incidence of acute malnutrition in pediatric patients with intracranial infection (p: 0.008, 95% CI: 0.076-0.675). The incidence of malnutrition in children with intracranial infections in Sanglah Hospital during January 2019 to March 2021 was 48.1%, and age < 5 years had significant relation to the incidence of malnutrition in children with intracranial infections.

Scalp Reconstruction Using Microvascular Free Tissue Transfer in the Patients with Intracranial Antibiotic-Resistant Bacteria Infection

Purpose: When scalp infection occurs after craniectomy and cranioplasty, it tends to be recurrent and fatal. The infection can spread to the underlying tissue when the skull is not present to act as a barrier, eventually leading to epidural abscesses and encephalitis. In such cases of widespread infection, reconstruction of scalp and skull defect after surgical debridement of infected tissue is a great challenge for plastic and neurosurgeons.Methods: Six patients with infection of forehead, scalp, and underlying dura were referred to our clinic for the control of repeated infection. Features and duration of infection, the presence of foreign bodies, bacterial culture tests, types of free flaps, and postoperative complications were investigated.Results: All cases were intracranial infections after neurosurgery and the duration of infection was 4.3±2.6 months. Foreign bodies (artificial bone, titanium mesh, plate, and screw) were present in three cases. Antibiotic-resistant bacteria were cultured in five cases (methicillin-resistant Staphylococcus aureus, methicillin-resistant coagulase-negative staphylococci, carbapenem-resistant Acinetobacter baumannii). For the control of infection, removal of foreign body and free tissue transfer was performed. The infection was controlled successfully during follow-up periods (59.3±42.0 months). Conclusion: Intracranial infections after neurosurgery on the skull can be fatal and lead to long-term sequelae. For the control of intracranial infection with antibiotic-resistant bacteria, well-vascularized free tissue transfer followed by foreign body removal is recommended. After infection control through free tissue transfer, secondary operations such as cranioplasty with titanium mesh or fat injection can be performed safely without recurrence of infection.