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Review

Intrathecal Antibacterial and Antifungal Therapies

Roland Nau, Claudia Blei, Helmut Eiffert
Roland Nau
aInstitute of Neuropathology, University Medical Center, Göttingen, Germany
bDepartment of Geriatrics, Protestant Hospital Göttingen-Weende, Göttingen, Germany
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Claudia Blei
cHospital Pharmacy, University Medical Center, Göttingen, Germany
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Helmut Eiffert
aInstitute of Neuropathology, University Medical Center, Göttingen, Germany
dAmedes MVZ for Laboratory Medicine, Medical Microbiology and Infectiology, Göttingen, Germany
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DOI: 10.1128/CMR.00190-19
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SUMMARY

Intrathecal administration of anti-infectives is indicated in central nervous system infections by multiresistant pathogens when drugs that can reach adequate cerebrospinal fluid (CSF) concentrations by systemic therapy are not available. Antibiotics that readily pass the blood-brain and blood-CSF barriers and/or that have low toxicity allowing an increase in the daily dosage should not be used for intrathecal therapy. Intrathecal therapy is accompanied by systemic treatment. Antibacterials indispensable for intrathecal therapy include aminoglycosides, colistin, daptomycin, tigecycline, and vancomycin. Limited experience suggests the utility of the antifungals amphotericin B and caspofungin. Intraventricular administration ensures distribution throughout the CSF compartment, whereas intralumbar dosing often fails to attain adequate antibiotic concentrations in the ventricles. The individual dose is determined by the estimated size of the CSF space and by the estimated clearance from CSF. For moderately lipophilic anti-infectives with a molecular weight above approximately 1,000 g/mol, as well as for hydrophilic drugs with a molecular weight above approximately 400 g/mol, one daily dose is normally adequate. The ventricular drain should be clamped for 15 to 120 min to facilitate the distribution of the anti-infective in the CSF space. Therapeutic drug monitoring of the trough levels is necessary only in cases of therapeutic failure.

This work is dedicated to Hilmar Prange on the occasion of his 75th birthday.

  • Copyright © 2020 American Society for Microbiology.

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Intrathecal Antibacterial and Antifungal Therapies
Roland Nau, Claudia Blei, Helmut Eiffert
Clinical Microbiology Reviews Apr 2020, 33 (3) e00190-19; DOI: 10.1128/CMR.00190-19

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Intrathecal Antibacterial and Antifungal Therapies
Roland Nau, Claudia Blei, Helmut Eiffert
Clinical Microbiology Reviews Apr 2020, 33 (3) e00190-19; DOI: 10.1128/CMR.00190-19
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  • Top
  • Article
    • SUMMARY
    • INTRODUCTION
    • ANATOMY AND PATHOPHYSIOLOGY
    • PHARMACODYNAMICS
    • ANTI-INFECTIVES USED FOR THERAPY OF CNS INFECTIONS
    • EVIDENCE FOR THE EFFECTIVENESS AND SAFETY OF INTRATHECAL ANTI-INFECTIVE THERAPY
    • PHARMACOKINETICS OF INTRATHECAL THERAPY: GENERAL ASPECTS
    • GENERAL RECOMMENDATIONS FOR INTRATHECAL THERAPY
    • PHARMACOKINETICS OF INDIVIDUAL COMPOUNDS
    • LIMITATIONS OF THIS REVIEW
    • CONCLUSIONS
    • ACKNOWLEDGMENTS
    • REFERENCES
    • Author Bios
  • Figures & Data
  • Info & Metrics
  • PDF

KEYWORDS

antibiotics
antifungal agents
brain abscess
cerebrospinal fluid
intrathecal
intraventricular
meningitis
ventricular shunt
ventriculitis

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