Surgical management of bacterial meningitis R.P. HUMPHREYS, MD, FRCS[C] A variety of associated lesions may require the neurosurgeon's assistance in the management of bacterial meningitis. As treatment of this infection of the central nervous system proceeds, the surgeon will have to decide about the concurrent or subsequent operative treatment of

Summary:

The first treatment of bacterial menin¬

gitis was surgical. A century before the bacterial origin of infection was recognized, Pott in 1760 defined precisely meningeal putrefaction and urged meticulous debridement of skull frac¬ tures to prevent this "very melancholy part of practice".1 Horsley first atcongenital dysraphic states, paraneural tempted surgical treatment of bacterial infections, compound fractures or meningitis 130 years later: he estab¬ lished continuous drainage of the cere¬ penetrating wounds of the cranium or spine, or infected bypass shunts for brospinal fluid (CSF) by means of lacerebrospinal fluid (CSF). In patients minectomy and irrigated the subarach¬ with intractable meningitic infections noid space with weak bichloride of the surgeon may have to insert a mercury solution.2 Thereafter surgical ventricular drainage-irrigation system methods were used for three main pur¬ to permit adequate perfusion of the poses: (a) application of antiseptics and CSF pathways with antibiotic. antisera; (b) drainage of CSF, continu¬ ous or intermittent; and (c) irrigation Hydrocephalus or subdural effusions of the cerebrospinal pathways with complicating meningitis may bring the patient to the surgeon long after the "physiological fluids".1 Subsequently infection has been cured. This paper ventricles were tapped, cisterna magna examines these problems and outlines and lumbar sacs drained or the whole the current principles of management. central nervous system (CNS) was washed by bland or antiseptic solu¬ tions.3 Resume: Le traitement chirurgical The success of sulfonamide therapy de la meningite bacterienne made it clear that the treatment of Diverses lesions secondaires peuvent, meningitis should be governed by bac¬ en certains cas, exiger le recours au teriologic considerations and surgery must be subsidiary. The last champion neurochirurgien pour traiter la of surgical support in bacterial menin¬ meningite bacterienne. A mesure que progresse le traitement de cette gitis was Cairns,1 who in 1949 adinfection du systeme nerveux central, vocated the intraventricular placement le chirurgien aura a prendre une of penicillin because it "does not pass decision concernant le traitement the blood-CSF barrier in sufficient amount and thus must be directly in¬ operatoire concomitant ou subsequent de dysraphies congenitales, d'infections troduced". paraneurales, de fractures composees Today, principles of antibiotic and ou de plaies penetrantes affectant le supportive drug therapy for bacterial crane ou I'epine, ou d'infections d'un meningitis are standardized.4"9 For the shunt de pontage pour le liquide patient over the age of 2 months with confirmed meningitis of unspecified c6phalorachidien (LCR). Chez les malades presentant une meningite type, ampicillin, 400 mg/kg »d is ad¬ ministered intravenously. If the patient rebelle, il se peut que le chirurgien soit oblige d'introduire un systeme de is less than 8 to 12 weeks old, genta¬ drainage et d'irrigation pour permettre micin, 7.5 mg/kg «d, given intramuscu¬ une perfusion suffisante des voies du larly, is added. Once the results of LCR par I'antibiotique. L'hydrocephalie sensitivity testing are known, penicillin, ou des epanchements sousduraux methicillin, cephaloridine or chloram¬ peuvent ramener le malade au phenicol may be included or substi¬ tuted. Anticonvulsants, steroids and hychirurgien longtemps apres que I'infection a ete guerie. Le present perosmotic agents may be administered article etudie ces problemes et rappelle les principes classiques du traitement.

From the division of neurological surgery, The Hospital for Sick Children, Toronto, and the University of Toronto Presented to the department of surgery "Gallie Day" at the University of Toronto, May 1974. Reprint requests to: Dr. R.P. Humphreys, Division of neurosurgery, Rm. 2223, The Hospital for Sick Children, 555 University Ave., Toronto, Ont. M5G 1X8

as

well.

Indications for

surgical management The neurosurgeon's assistance is re¬ quired in four general categories of meningitis in which the bacteriologically appropriate medication is thera¬ peutically inadequate. These categories are

summarized in Table I.

536 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113

Meningitis

as a

occult disease Bacterial ary to

an

manifestation of

meningitis

may be second¬

occult, primary, underlying

CNS disease that has permitted bac¬ terial invasion of the subarachnoid pathways, should have received pro¬ phylactic surgical treatment and will now

require surgical

treatment.

The classic example is the child who has repeated episodes of bacterial men¬ ingitis due to an undetected dermal sinus tract leading from the subarach¬ noid space to the body surface.5'10,11 Two other embryologie tissues may communicate, as with a neurenteric cyst. Meningitis may signal an under¬ lying inflammation of the CNS, paranasal sinuses or middle ear, previously evident but now overlooked after the patient has become acutely ill with bacterial meningitis.12 Meningitis may also occasionally be a manifestation of brain abscess.13,14 In this category clearly the menin¬ gitis must be treated effectively first, then the associated CNS disease defined and treated. Prophylactic surgery in a patient with a dermal sinus tract or neurenteric cyst is recommended not only for prevention of meningitis but also because the lesion may be easily corrected before meningitis produces an Table I.Indications for neurosurgical management of bacterial meningitis

inflammatory reaction

placement of a CSF diversionary shunt. Formerly, the most efficient way to eradicate the infection was total shunt removal coupled with daily CSF reMeningitis complicating a surgically trieval and systemic antibiotic adminis¬ treatable lesion tration. But alternatives are available, The commonest and perhaps most such as immediate shunt replacement controversial indication for surgical and systemic antibiotic coverage, or treatment of meningitis is complication use of intraventricular antibiotics with¬ by meningitis of a primary underlying in the existing shunt system.28,29 In CNS disease that itself requires sur¬ some instances we have found partial removal of the shunt system useful. gical care. Most infants born with myelomenin- The lower end of the shunt is attached gocele or encephalocele acquire infec¬ to an external collecting device, allow¬ tion from the birth canal and conta¬ ing continuous drainage of the infected minated perineum during delivery. With CSF, decompression of the CSF path¬ rupture of the protective myelomenin- ways, daily sampling of CSF and gocele sac, retrograde contamination of easy administration of intraventricular the subarachnoid space is a major drugs. After the CSF has been sterile threat. Hence, surgical closure of spina for 7 days the indwelling ventricular bifida cystica is recommended not so catheter is removed and a new shunt much to preserve leg function as to inserted. In the past 4 years (January diminish the risk of meningitis.11 1971 to December 1974) we have used Meningitis frequently complicates this technique with six children. For trauma to the CNS, particularly com¬ another eight children with intractable pound fractures or penetrating wounds infections the entire shunt system was of the cranium or spine. It was about removed and replaced with an external this situation that Pott originally ex¬ ventricular drain; in all but one in¬ pressed his concern. Today, surgeons stance bacteriologic cure was obtained are more concerned with meningitis and a new indwelling shunt system sub¬ that occurs with or is alleged to threat- sequently placed. en CSF fistulas.15,16 The incidence of bacterial meningitis at any future time Failure of nonsurgical therapy in in a patient with a basal skull fracture of meningitis management producing CSF rhinorrhea or otorrhea In most episodes of neonatal menin¬ has been estimated at 25 to 50% .17"22 Because of this threat many advocate gitis, improving clinical, hematologic prophylactic antibiotic therapy, or sur¬ and CSF cell responses are noted with¬ gical exploration and closure of the in a few days of the initiation of intra¬ fistula, or both.17*27 Most surgeons have venous antibiotic therapy. Sometimes, been conservative, choosing long-term however, antibiotics administered by prophylactic antibiotic coverage and, the intravenous or even lumbar intrawhen leakage persists or recurs, obli- thecal routes do not enter the intra¬ teration of the fistula. Understandably, cranial CSF-containing spaces. The there has never been a double-blind reasons for this are uncertain but prob¬ study of treatment of CSF fistulas. ably include failure of drug transport Meningitis may also complicate the to the CSF, dilution of the drug by adhesive

in the

area.

FIG. 1.Computer tomogram of 3-month-old infant with postmeningitic hydrocephalus due to obstruction of outlets of fourth ventricle.

CSF, and occlusion of the Sylvian

aqueduct or outlets of the fourth ven¬ by inspissated pus.5,30,31 If a child (especially a neonate) is desperately ill

tricle

admission, in a toxic condition and in shock, or if the child's condition fails to improve as expected, especially if microorganisms can still be cultured in the ventricular CSF when the lum¬ bar CSF is sterile, one should consider on

placing an external ventricular drain (particularly if the child has acute hydrocephalus) or a ventricular cathe¬ ter connected to a subcutaneous re¬ servoir. Through either system one can obtain daily CSF specimens and ad¬ minister antibiotics by barbotage into the ventricular cavities.31"34 We have used external drainage for nine chil¬

dren and the ventricular catheter/re¬ servoir system for six others, all with intractable meningitis, over the past 4 years. Three children of the first group and two of the second died from their infections 24 hours to 3 weeks after these maneuvers. In those who lived the CSF became sterile and the ventri¬ cular catheters and reservoirs were re¬ moved an average of 7 days after insertion. This apparatus must always be removed after treatment, otherwise bacterial colonization of the catheters can cause

reinfection.

or intra¬ ventricular chemotherapy we have avoided penicillin and selected instead

In all lumbar intrathecal

cephaloridine, chloramphenicol

or

gen¬

tamicin.

Late complications of meningitis The most common late complications of bacterial meningitis are hydroce¬ phalus and subdural effusions.5,35"39 Cer¬ tain microorganisms (especially Hemo¬ philus influenzae) tend, for unknown reasons, to

which

produce subdural effusions, of fever,

can cause recurrence

FIG. 2.Ventriculogram 48 hours after injection of 100 /*Ci of inIn-labelled DTPA (diethylenetriaminepentacetic acid) into right lateral ventricle: no circulation of radioisotope through ventricular system to cisterna magna. CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113 537

irritability, vomiting and rapid expansion of an infant's head. Percutaneous subdural tap is both diagnostic and therapeutic; repeated aspiration or perhaps drainage by means of burr holes, subdural-peritoneal shunt or even craniotomy may be required to eliminate the subdural collection of fluid.11'3548 Hydrocephalus either of the obstructive or communicating variety may coexist with meningitis during treatment of the latter or may arise several days, weeks or months later. During treatment of meningitis external ventricular drainage for acute hydrocephalus effects CSF pathway decompression and provides a route for antibiotic administration. There can be little doubt about the diagnosis in a child who has recovered from the CNS infection but shows subsequent signs of intracranial hypertension (if subdural effusions have been ruled out). Air encephalography or ventriculography has been the traditional method to confirm the diagnosis, but simpler techniques are now available to study the static and dynamic aspects of the hindered flow of CSF. Computer tomography outlines the enlarged ventricular cavities (Fig. 1) and subsequent radiopharmaceutical cisternography or ventriculography provides an analysis of CSF movement (Fig. 2). After confirmation of the specific type of hydrocephalus the appropriate CSF shunting device can be surgically inserted. Conclusion Today Pott, Horsley, Dandy and Cairns might still applaud the neurosurgeon's association with the patient who has bacterial meningitis - a contact that may occur before the infection starts, after it is over or anytime in between. We would urge the surgeon's early involvement in the therapy of the patient with problematic meningitis. Patients referred to in this paper were treated in the perinatal unit (Dr. P.R. Swyer, director), the infectious service (Dr. C.S. Anglin, director) or the neurosurgical unit, by Drs. E.B. Hendrick, HJ. Hoffman and the author. References 1. CAIRNS H: Surgical aspects of meningitis. Br Med 1 1: 969, 1949 2. ADELOYE A, OYEDEJI GA: Surgical aspects of nontuberculous bacterial meningitis in infancy and childhood. The successful use of conservative surgery in management of some of its complications. Clin Pedlatr (Phila) 12: 589, 1973 3. DANDY WE: The treatment of staphylococcus and streptococcus meningitis by continuous drainage of the cisterna magna. Surg Gynecol Obstet 39: 760, 1924 4. ANGLIN CS, TURNER JAP, Doaa. MJ, et al: Meningitis in infants and children. Mod Med Can 27: 453, 1972 5. LERNER P1: Selection of antimicrobial agents in bacterial infections of the nervous system, in Advances in Neurology: Infectious Diseases of the Central Nervous System, vol 6, edited by THOMPSON RA GREEN JR. New York, Raven, 1974, p 164

6. NANKERVIS GA: Bacterial meningitis. Med Clin North Am 58: 581, 1974 7. SWARTZ MN, DODGE PR: Bacterial meningitis - a review of selected aspects. 1. General clinical features, special problems and unusual meningeal reaction mimicking bacterial meningitis. N Engi I Med 272: 725-32, 77987, 842-48, 898-902, 9541009, 1965 8. WEHRLE PF, MAntlEs AW jst, LEEDOM 3M: Management of bacterial meningitis. Clin Neurosurg 14: 72, 1966 9. Idem: The critically ill child: management of acute bacterial meningitis. Pediatrics 44: 991, 1969 10. MATSON DD, JERVA MI: Recurrent meningitis associated with congenital lumbosacral dermal sinus tract. I Neurosurg 25: 288, 1966

11. MATSON DD: Neurosurgery of infancy and childhood, second ed, Springfield, IL, CC Thomas, 1969, chap 1, p 5 12. BEERHUIS GJ, TAYLOR M: Ear and sinus aspects of intracranial suppurative disease (chap 2), in Cranial & Intracranial Suppura-

tion, edited by GURD.TIAN ES, Springfield, IL, CC Thomas, 1969, p 42 13. GURDJIAN ES, THOMAS LM: Surgical treatment of cranial and intracranial suppuration, (chap 1), in Ibid, p 3 14. LEBEAu 3, CRaIssARD P, HARISPE L, et al: Surgical treatment of brain abscess and subdural empyema. I Neurosurg 38: 198, 1973

15. HAND WL, SANDFO1tD IP: Posttraumatic bacterial meningitis. Ann Intern Med 72: 869, 1970 16. MACGEE EE, CAUTHEN IC, BstAcscErr CE: Meningitis following acute traumatic cerebrospinal fluid fistula. J Neurosurg 33: 312, 1970 17. LEWIN W: The Management of Head Injuries. London, Bailliere, Tindall & Cassell, 1966, chap 9, p 155 18. MORLEY TP, HETHERINGTON RH: Traumatic cerebrospinal fluid rhinorrhea and otorrhea, pneumocephalus and meningitis. Surg Gynecol Obstet 104: 88, 1957 19. NORTH JB: On the importance of intracranial air. Br I Surg 58: 826, 1971 20. RAAF I: Posttraumatic cerebrospinal fluid

leaks. Arch Surg 95: 648, 1967 21. RAY BS, BERGLAND RM: Cerebrospinal fluid fistula: clinical aspects, techniques of localization and methods of closure. I Neurosurg 30: 399, 1969 22. RoBINsON RG: Cerebrospinal fluid rhinorrhoea, meningitis and pneumocephalus due to non-missile injuries. Aust NZ I Surg 39:

328, 1970

23. BRAWLEY BW, KELLY WA: Treatment of basal skull fractures with and without cerebrospinal fluid fistula. I Neurosurg 26: 57, 1967 24. CALDICOTT WJH, NORTH JB, SIMPSON DA: Traumatic cerebrospinal fluid fistulas in children. I Neurosurg 38: 1, 1973 25. DINNING TA, SIMPSON DA, TASSIE JA: Infection complicating head injury. The value of preventive surgery. Aust NZ I Surg 30: 191, 1961 26. JAMIESON KG, YELLAND JDN: Surgical repalr

27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38.

39.

of the anterior fossa because of rhinorrhea, aerocele, or meningitis. I Neurosurg 39: 328, 1973 JEFFERSON A, REILLY G: Fractures of the floor of the anterior cranial fossa. The selection of patients for dural repair. Br I Surg 59: 585, 1972 McLAURIN RL: Infected cerebrospinal fluid shunts. Surg Neurol 1: 191, 1973 PERRIN ICS, McLAURIN RL: Infected ventriculo-atrial shunts. A method of treatment. I Neurosurg 27: 21, 1967 GARROD LP, O'GRADY F: Antibiotics and Chemotherapy. Edinburgh & London, Churchill Livingstone, 1972, p 325 SALMON JH: Ventriculitis complicating meningitis. Am I Dis Child 124: 35, 1972 RATCHESON RA, OMMAYA AK: Experience with the subcutaneous cerebrospinal fluid reservoir. Preliminary report of 60 cases. N Engi I Med 279: 1025, 1968 STARK G: Treatment of ventriculitis in hydrocephalic infants: intracranial and intraventricular use of the new penicillins. Dev Med Child Neurol 15 (suppl): 36, 1968 WHANG CJ, CAUTHEN JC, GARCIA-BENGOCILEA F: Successful treatment of ventriculitis by continuous intraventricular irrigation with gentamicin solution. Surg Neurol 2: 91, 1974 GOODMAN 3M, MEALY I JR: Postmeningitic subdural effusions: the syndrome and its management. I Neurosurg 30: 658, 1969 Moms PD, THOMPSON GB, CLUFF JW: Subdural peritoneal shunts in the treatment of subdural effusions in infants. I Neurosurg 23: 584, 1965 Moms PD: Subdural effusions in infants. Can Med Assoc 1 100: 231, 1969 RABE EF, FLYNN RE, DODGE PR: Subdural collections of fluid in infants and children: study of 62 patients with special reference to factors influencing prognosis and efficacy of various forms of therapy. Neurology 18: 559, 1968 Scssuui-z P, LEEDS NE: Intraventricular septalions complicating neonatal meningitis. I Neurosurg 38: 620, 1973

538 CMA JOURNAL/SEPTEMBER 20, 1975/VOL. 113

Data from over 30,000 cases provide convincing evidence of: Exemplary therapeutic efficacy, minimal bacterial resistance, excellent tolerance. Destructive to the life cycle of pathogens by unique metabolic blockade, 'Bactrim' 'Roche' is now established as a standard among wide spectrum antibacterial agents. It has proved of particular value in treating infections of respiratory and gen ito-urinary tracts.

'Bactrim' 'Roche' a new generation antibacterial Ri Summary Bactrim' Roclw indications:

Indicated for the following infections when caused by susceptible pathogens. * Upper and lower respiratory tract infections (particularly chronic bronchitis and including acute and chronic otitis media). mAcute, recurrent, and chronic urinary tract infections. * Genital tract infections (uncomplicated gonococcal urethritis). *Gastrointestinal tract infections. * Skin and soft tissue Infections. * Not indicated in infections associated with Pseudomonas, Mycoplasma, nor when the infection is caused by a virus.

Contraindication.:

In patients with evidence of marked liver damage, blood dyscrasias, or with a known hypersensitivity to trimethoprim or sulfonamides or in patients with marked renal impairment where repeated serum assays cannot be carried out. Should not be given to premature or to newborn infants during the first few weeks of life. For the time being, it is contraindicated during pregnancy.

Pmcautlons:

As with other sulfonamide preparations, benefit should be critically appraised versus risk in patients with liver damage, renal damage, urinary obstructions, blood dyscrasias, allergies or bronchial asthma. The possibility of suparinfection with a nonsensitive organism should be borne in mind.

Dosag. and AdmInIstratIon:

Standard dosage: Two tablets twice daily (morning and evening). Minimum dosage and dosage for long-term treatment: One tablet twice daily. Maximum dosage: Overwhelming infections - Three tablets twice daily. Uncomplicated gonorrhea - Two tablets four times daily for two days. Children under 12 years of age: Young children should receive a dose according to biological age: Children under 2 years: 2.5 ml pediatric suspension twice daily. Children2to5years:Onetotwopediatrictabletsor 2.5 to 5 ml pediatric suspension twice daily. Children 6 to 12 yasra: Two to four pediatric tablets or 5 to 10 ml pediatric suspension or one adult tablet twice daily. Supply: Bactrim Roche: Adult Tablets (white) containing 400 mg sulfamethoxazole and 80 mg trimethoprim. Bottles of 100 and 500. Blister pecks of 20. Unit dose of 100(5 x 5 x 4). Pediatric tablets (white) containing 100 mg sulfamethoxazole and 20 mg trimethoprim. Bottles of 100 and 500. Blister packs of 20. Pediatric suspension (aniseed flavoured): Each teaspoonful (5 ml) containing 200 mg sulfamethoxazole and 40 mg trimethoprim. Boftles of 100 and 400 ml. Product monograph available on request. * Trade Mark of Hoffmann-La Roche Limited ®Reg.Trade Mark

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