Central nervous system infections requiring treatment with intraventricular (IVT)
vancomycin are becoming increasingly common with advent of intracranial devices and increasing prevalence of multi-
drug resistant and nosocomial organisms. Administering
vancomycin via IVT route bypasses the blood-brain barrier to allow localized and controlled delivery directly to the desired site of action, achieving high concentrations for more reliable bactericidal action. This article systematically reviews current literature on IVT
vancomycin in adults, compiles current knowledge, and integrates available evidence to serve as a practical reference.Medline (1946-July 2012), Embase (1974-July 2012), and International
Pharmaceutical Abstracts (1970-July 2012) were searched using terms
vancomycin, intraventricular, shunt
infection, cerebrospinal fluid, and intraventriculitis. Seventeen articles were included in this review. Indications for IVT
vancomycin included
meningitis unresponsive to intravenous
antibiotics, ventriculitis, and intracranial device
infections. No serious adverse effects following IVT
vancomycin have been reported. Dosages reported in literature ranged from 0.075-50 mg/day, with the most evidence for dosages of 5 to 20 mg/day.
Duration of therapy most commonly ranged from 7 to 21 days. Therapeutic
drug monitoring was reported in 11 studies, with CSF
vancomycin levels varying widely from 1.1 to 812.6 mg/L, without clear relationships between CSF levels and efficacy or toxicity. Using IVT
vancomycin to treat
meningitis, ventriculitis, and CNS device-associated
infections appears safe and effective based on current evidence. Optimal regimens are still unclear, and dosing of IVT
vancomycin requires intricate consideration of patient specific factors and their impact on CNS pathophysiology. Higher-quality clinical trials are necessary to characterize the disposition of
vancomycin within CNS, and to determine models for various pathophysiological conditions to facilitate better understanding of effects on pharmacokinetic and pharmacodynamic parameters.