P-464. Challenges of Microbiological Diagnosis and Targeted Treatment of Pediatric Sinogenic Intracranial Infections

TL;DR

This study examines the challenges of diagnosing and treating pediatric intracranial infections from sinusitis, finding that infections are often polymicrobial and that CNS cultures are crucial for accurate treatment.

Contribution

The study provides insights into the polymicrobial nature of these infections and the importance of CNS cultures for guiding antibiotic treatment.

Findings

Most cases of sinogenic intracranial infections are polymicrobial, often involving Streptococcus anginosus group and anaerobes.

Microbiologic results from sinus and CNS cultures frequently differ, highlighting the importance of CNS cultures for accurate treatment guidance.

Antibiotic treatments like ceftriaxone/metronidazole and carbapenems were equally effective with low rates of long-term neurological complications.

Abstract

Intracranial extension of infectious sinusitis is a rare but potentially life-threatening childhood disease with increasing incidence. Streptococcus anginosus group (SAG) species are the most frequently identified pathogens, but infections are often polymicrobial. Current guidelines do not address potential use of ertapenem for this infection.

We performed a retrospective chart review of patients admitted to Primary Children’s Hospital with ICD9 and ICD10 diagnoses of sinusitis and intracranial infection between 2004 and 2019. We compared microbiologic data from surgical cultures by anatomic site, and course and outcomes stratified by culture-guided antibiotic treatment.

We evaluated 85 sinogenic intracranial infections. Most patients (n=81) underwent surgical debridement. Surgical cultures from the sinus (n=62) and central nervous system (CNS, n=67) were reviewed. Multiple bacteria were identified in 62% of cases. SAG were the most commonly identified pathogen (n=44). Most patients had surgical cultures from the sinus and CNS (n=48). Microbiologic results were discordant between sites in 83% of cases, including Staphylococcus aureus detected only in sinus cultures (n=12) and SAG detected only from CNS cultures (n=10). Anaerobic organisms were identified in 32% of patients overall, but discordant for 60% of patients with both cultures. CNS culture-guided antibiotics included ceftriaxone/metronidazole (n=36), ertapenem (n=22), meropenem (n=11), and other combinations (n=16). Neurologic complications persisting at 1-year were rare and included epilepsy and hemiparesis. There were no statistically significant differences in surgical management or chronic neurologic complications between treatment groups.

Sinogenic intracranial infections are typically polymicrobial including SAG and anaerobes. Timely CNS surgical cultures are important to guide treatment. Sinus culture data may not accurately reflect CNS pathogens. Culture directed antibiotic treatment with ceftriaxone/metronidazole and carbapenems were equally effective with similarly low rates of long-term neurologic sequelae. Additional data is needed to inform generalizability of these findings.

Anne J. Blaschke, MD, PhD, BioFire Diagnostics/Biomerieux: I have IP owned by the U. of Utah licensed to BioFire and receive royalties.|Merck & Co: Advisor/Consultant