神经外科重症患者革兰阴性菌致急性化脓性脑室炎的诊断和治疗

Diagnosis and treatment of pyogenic ventriculitis caused by gram-negative bacteria in severe neurosurgical patients

目的探讨神经外科重症患者革兰阴性（G-）菌致急性化脓性脑室炎的诊疗经验。方法回顾性分析首都医科大学宣武医院神经外科重症监护病房2009年9月至2014年8月连续收治的19例急性化脓性脑室炎患者，分析其细菌学结果、临床治疗及预后。结果所有患者脑室引流脑脊液细菌涂片均为G-菌，头颅cT检查证实为脑室内积脓。脑脊液细菌培养18例阳性，其中鲍曼不动杆菌12例，肺炎克雷伯杆菌2例，粘质沙雷菌2例，嗜麦芽假单胞菌1例，大肠埃希菌1例。1例细菌培养阴性。所有病例去除引起感染的导管，行脑室外引流，根据病情脑室内灌洗联合静脉用药和脑室内抗生素治疗，随访3个月至3年。经过治疗2～8周，14例治愈（74％），5例死亡（26％）。治愈的患者中8例因脑积水于感染治愈2～6周行脑室-腹腔分流术，无再次感染；意识恢复清醒12例，2例感染前已处于植物状态患者无改善。结论神经外科重症患者急性化脓性脑室炎主要由G-菌引起，病死率较高，早期诊断特别是明确病原菌、及时予以脑室灌洗、脑室引流联合静脉及脑室内抗生素治疗，能提高治愈率，改善预后。

Objective To investigate ventrieulitis caused by gram-negative bacteria （ G - the experiences in diagnosis and treatment pyogenic ） in severe neurosurgical patients. Methods Nineteen consecutive patients with pyogenic ventriculitis treated at the Neurosurgical Intensive Care Unit of the Department of Neurosurgery, Beijing Xuanwu Hospital, Capital Medical University from September 2009 to August 2014 were reviewed. Their bacteriological results, clinical treatment, and prognosis were analyzed. Results Ventricular drainage of cerebrospinal fluid bacterial smears in all cases were G- bacteria. Head CT scans confirmed as intraventricular empyema. Eighteen patients were positive in cerebrospinal fluid bacterial culture, 12 of them were Acinetobacter baumannii, 2 were Klebsiella pneumonia, 2 were Serratia marcescens, 1 was Pseudomonas maltophila, and 1 was Escherichia coll. The bacterial culture in one case was negative. The catheters which caused infections were removed and ventricular drainage was conducted in all cases. The patients were treated with intraventricular lavage in combination with intravenous drugs and intraventricular antibiotics according to the conditions. They were followed up for 3 months to 3 years. After treatment for 2 to 8 weeks, 14 patients were cured （74%） and 5 died （26%）. In the cured patients, 8 patients underwent ventriculo-peritoneal shunt after the infection being cured in 2 to 6 weeks because of hydrocephalus. No reinfection occurred. Twelve patients came to consciousness, and 2 were in a persistent vegetative state before infection and did not have any improvement. Conclusions Suppurative ventriculitis in severe neurosurgical patients is mainly caused by G- negative bacteria. The mortality is higher. Early diagnosis, especially clarifying pathogens, timely ventricular irrigation, and ventricular drainage in combination with intravenous and intraventricular antibiotic treatment may increase the cure rate and improve the prognosis.