Question 1

a) Discuss the assessment and challenges of diagnosing ventriculitis in a febrile patient with a subarachnoid haemorrhage (SAH) and an external ventricular drain (EVD) in situ. (6 marks)

b) Outline the principles of management if a diagnosis of EVD-related ventriculitis is strongly suspected or confirmed. (4 marks)

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College answer

Syllabus topic/section:
2.1.3 Sepsis and Infections – L1.
2.1.8 Neurological Intensive Care – L1.
1. To ask the candidate to demonstrate knowledge of assessment of the diagnosis of EVD related ventriculitis.
2. To test application of this knowledge to the clinical context and discuss the challenges of using the diagnostic criteria in a critically unwell patient.
3. To test knowledge of broad principles of management of EVD related ventriculitis.
To demonstrate competency of the subject, the answer needed to address every element requested in the stem. For part A candidate answers that addressed the assessment AND challenges as requested gained higher marks.
Examples of challenges include the difficulty of an accepted definition of ventriculitis, inflammatory changes due to brain injury with the presence of the EVD and features associated with SAH which will mask the features of infection amongst others. Candidates using the glossary of terms who structed their answer in terms of history (including risk factors for ventriculitis, e.g. patient related, and catheter related factors) examination findings and targeted investigations with rationale gained higher marks.
In Part B the expected transitional fellow level standard contained details of antibiotic choice and rationale, as well as a discussion on the management of the EVD and patient related factors. Ventriculitis is a pathology that has a specific therapy of antimicrobials and little requirement for ongoing source control, unlike, for example, pancreatitis. It is therefore necessary to go into detail about choice, rationale, timing, duration, and route in the explanation of antibiotics in this setting This is particularly important in severe ventriculitis where the intraventricular route is required for treatment resistant cases.

Marking rubric:

Part A

Assessment and challenges

6 marks

Inadequate detail

Doesn’t appreciate the challenges of diagnosis.

0-2 marks

Has knowledge of how to diagnose ventriculitis but has not demonstrated the challenges in the critically unwell patient.

2-3 marks

Good detail present.

Able to appreciate some of the challenges of making diagnosis of ventriculitis in poor detail.

3-4 marks

Contained applied clinical perspective.

Detailed and nuanced answer, Able to appreciate the challenges of making the diagnosis of ventriculitis.

5-6 marks

Part B

Principles of management

4 marks

Superficial answer, minimal details about antibiotic choice.

Minimal or no discussion about EVD.

<2 marks

Addresses antibiotics, EVD in limited detail.

1-2 marks

Improved structured answer with more detail.

Some organisation attempt of details.

2-3 marks

Detailed and nuanced answer

Included antibiotic choice, dose and rationale, management of EVD and considerations relating to change.

4 marks


This was the first time the exam was reported upon with so much luxurious detail, with marking rubrics and blueprinting links to the Syllabus for the Second Part Examination.  The greatest challenge going forward for this sort of armchair commentary will no longer be the need to guess what was in the minds of the examiners when they wrote the paper, but how to craft an answer fit to get the maximum marks.

An additional point of interest is the removal of the "pass rate" metric, and its replacement with the Angoff score, as a better measure of question difficulty. This should be of immediate interest to everybody. The SAQs which had a pass rate of (for example) 0% in previous years (you know the ones I mean) were not the most difficult per se, they were just met with a group of trainees who were especially unprepared for this specific SAQ (it having never been seen before, and past papers being the favoured method or preparation). The question itself (eg. "list the key clinical signs of traumatic asphyxia") was not itself remarkable by the degree of knowledge or analysis it expected, but nobody knew the answer anyway. Theoretically, a group of trainees who all somehow expected a traumatic asphyxia question would have fallen into a normal distribution with the fat part somewhere around 5. The Angoff score is therefore a better metric, as it does not rely on the exam candidates level of preparation.

Anyway: a "discuss" answer will require some detail, for six marks:


Assessment of suspected ventriculitis:

  • Risk factors:

    • Patient characteristics:

      • Intraventrciular blood

      • Systemic infection

      • Duration of catheterization (11 days seems to be the cutoff for increasing risk of infection)

      • Immune compromise

    • Features of surgery:

      • Craniotomy (vs burrhole)

      • Superficial surgical site infections

      • CSF leakage

    • Catheter management

      • EVD, rather than a parenchymal pressure transducer

      • Frequent sampling

      • EVD irrigation

      • Non-tunnelled vs. tunnelled EVD

  • Symptoms

    • Headache

    • Photophobia

    • Neck pain

  • Physical signs

    • Unexplained decrease in the level of consciousness 
    • Fever 
    • Neck stiffness
    • New cranial nerve signs
    • Seizures
    • Features of meningism (eg. Kernig and Brudzinski signs)
    • Tenderness over the site of EVD insertion
  • Investigations

    • Peripheral blood
      • Increasing inflammatory markers
      • Positive blood cultures
    • CSF analysis
      • Culture, Gram stain
      • Cell count (WCC/RBC ratio of 1:106 or a rising trend)
      • Nucleic acid amplification tests for specific pathogens
      • β–D-glucan and galactomannan for fungal ventriculitis
    • Imaging
      • MRI with gadolinium could be helpful, or at least more helpful than CT

Challenges of diagnosing ventriculitis:

  • Definition of ventriculitis and diagnostic criteria are vague and not universally accepted
  • Inflammatory change in CSF promotes sterile pleocytosis
  • CSF cell count threshold is not agreed upon
  • CSF cell count fluctuates dramatically even with sequential sampling
  • Not all organisms will show up on a Gram stain
  • History and examination are difficult in the unconscious patient
  • Other causes of fever are common (eg. VAP, "central" fever)

Management of ventriculitis

  • Source control:
    • Remove the EVD if at all possible to survive without ICP monitoring and CSF drainage
    • Replace the EVD with a sterile parenchymal monitor, if is still necessary to monitor the ICP but where CSF drainage is not essential
    • If you absolutely need CSF drainage, perhaps remove the EVD and reinsert a new one after at least 48 hours of effective antibiotic therapy
    • If you absolutely cannot remove the EVD, at least open it continuously, to let the infected CSF drain out. 
  • Systemic antibiotics
    • Empiric treatment is with vancomycin and an anti-pseudomonal beta-lactam (such as cefepime, ceftazidime, or meropenem) - these are the IDSA-recommended agents
    • Doses of these agents have to be adjusted to permit penetration into the CSF
  • Intrathecal antibiotics for patients with treatment failure


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