Cerebrospinal fluid shunt infections

Agent	Age ^a	Total daily dose	No. daily doses
Ampicillin	Neonate <7 days	150 mg/kg	3
	Neonate 8–28 days	200 mg/kg	4
	Children	300 mg/kg	4
	Adults	12 g	6
Cefepime	Neonate <7 days	−
	Neonate 8–28 days	−
	Children	150 mg/kg	3
	Adults	6 g	3
Cefotaxime	Neonate <7 days	100–150 mg/kg^a	2–3
	Neonate 8–28 days	150–200 mg/kg	3–4
	Children	300 mg/kg	4–6
	Adults	8–12 g	4–6
Ceftazidime	Neonate <7 days	100–150 mg/kg^a	2–3
	Neonate 8–28 days	150 mg/kg	3
	Children	150 mg/kg	3
	Adults	6 g	3
Ceftriaxone	Neonate <7 days	−
	Neonate 8–28 days	−
	Children	100 mg/kg	2
	Adults	4 g	2
Meropenem	Neonate <7 days	−
	Neonate 8–28 days	−
	Children	120 mg/mL	3
	Adults	6 g	3
Nafcillin	Neonate <7 days	75 mg/kg	2–3
	Neonate 8–28 days	100–150 mg/kg^a	3–4
	Children	200 mg/kg	4–6
	Adults	9–12 g	6
Oxacillin	Neonate <7 days	75 mg/kg	2–3
	Neonate 8–28 days	150–200 mg/kg^a	3–4
	Children	200 mg/kg	4
	Adults	9–12 g	6
Penicillin G	Neonate <7 days	150 000 units/kg	2–3
	Neonate 8–28 days	200 000 units/kg	3–4
	Children	300 000 units/kg	4–6
	Adults	24 000 000 units	6
Rifampin	Neonate <7 days	−
	Neonate 8–28 days	10–20 mg/kg	2
	Children	10–20 mg/kg	1–2
	Adults	600 mg	1
Vancomycin	Neonate <7 days	20–30 mg/kg	2–3
	Neonate 8–28 days	30–45 mg/kg	3–4
	Children	60 mg/kg	4
	Adults	30–45 mg/kg	2–3

^a Lower doses and increased intervals are advisable for infants weighing <2000 g

Poor blood–brain barrier penetration is a significant problem with some antimicrobial agents used to treat shunt infections, most notably vancomycin. Serum vancomycin levels should be monitored, aiming for peak concentrations of 30 to 45 µg/mL and trough concentrations of 15 to 20 µg/mL. Effective CSF concentrations of vancomycin, aminoglycosides, and certain other antimicrobial agents can often be more easily achieved by antimicrobial administration into the cerebral ventricles. No prospective randomized trials have compared combined parenteral and intraventricular administration of antimicrobials with parenteral therapy alone. Intraventricular administration is commonly made use of, nonetheless, in patients with suboptimal responses to systemic antibiotics and patients for whom shunt removal is not feasible. Some authorities advocate the routine use of intraventricular antimicrobials in infection caused by susceptible organisms. No antimicrobial agents are currently licensed for intraventricular use. Intraventricular vancomycin and aminoglycosides, however, have few reported adverse affects when used at appropriate concentrations (Table 82.2

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