Ventricular Shunt Obstruction/Infection — Antibiotic Recommendations — Clinical Pathway: Emergency, ICU and Inpatient

Ventricular Shunt Obstruction/Infection Clinical Pathway — Emergency, ICU and Inpatient

Guidelines for the Empiric Treatment of Ventricular Shunt Infections in Children

First-Line Therapy
Includes Most Patients with Allergies to Penicillins		 Allergy to First-Line β-Lactam
Assess Need for Alternative		 Comments/Other Considerations
  • Cefepime, IV
  • < 50 kg
    • 50 mg/kg/dose every 8 hours
      Maximum: 2,000 mg/dose
  • ≥ 50 kg and/or ≥ 18 years
    • 2,000 mg every 8 hours
  • and
  • Vancomycin, IV
  • < 50 kg
    • 15 mg/kg/dose every 6 hours
      Maximum: 750 mg/dose
  • ≥ 50 kg and/or > 18 years
    • 15 mg/kg/dose every 8 hours
      Maximum: 1,000 mg/dose
  • Ciprofloxacin, IV
  • < 40 kg
    • 10 mg /kg/dose every 8 hours
    • Maximum: 400 mg/dose
  • ≥ 40 kg
    • 400 mg every 8 hours
  • and
  • Vancomycin, IV
  • < 50 kg
    • 15 mg/kg/dose every 6 hours
      Maximum: 750 mg/dose
  • ≥ 50 kg and/or > 18 years
    • 15 mg/kg/dose every 8 hours
      Maximum: 1,000 mg/dose
  • Give cefepime, ciprofloxacin, or meropenem and vancomycin
  • If CSF Gram stain positive for Gram-negative rods, change therapy to meropenem and vancomycin and suggest ID consult
    • Meropenem, IV
    • ≥ 1 month and < 50 kg
      • 40 mg/kg/dose every 8 hours
      • Maximum: 2,000 mg/dose
    • ≥ 50 kg and/or ≥ 18 years
      • 2,000 mg every 8 hours
  • Prior infection with resistant organism, suggest consult with Infectious Diseases
    • Review the patient’s multidrug-resistant organism (MDRO) tab in Epic and all culture results from the past year. Resistant organisms include any Gram-negative organism resistant to third-generation cephalosporins (extended-spectrum beta-lactamase organisms), carbapenems, or patients with a label of “RGN,” “CRE,” or “ESBL.”

CHOP Formulary for complete drug information.

Definitive Treatment Guidelines

  • Infected shunt material should be completely removed and an external ventricular drain placed
  • Obtain daily CSF cultures until 3 consecutive cultures have had no growth for 48 hours
  • Consider ID consult for bacteria identified on CSF gram stain, positive CSF cultures, or other high suspicions for CSF infection
    • e.g., brain abscess or empyema
  • A period off antibiotics before reinternalization is not recommended
  • Peri-operative antibiotics at the time of reinternalization should cover the organism responsible for the VP shunt infection and skin flora
  • Post-operative prophylactic antibiotics should continue no longer than 24 hours beyond the operating room for patients who have completed the treatment course at the time of reinternalization; otherwise, antibiotic duration should adhere to the recommendations made in the definitive treatment recommendations by organism
  • See Definitive Treatment Recommendations for Documented VP Shunt Infections