Systemic plus Local Antimicrobial Therapy for Post-Neurosurgical CRKP CNS Infections: A Case Series and Literature Review.

OBJECTIVE: To analyze the clinical features, treatment strategies, and outcomes of post-neurosurgical carbapenem-resistant Klebsiella pneumoniae (CRKP) CNS infections, emphasizing combined systemic/local antimicrobial therapy, therapeutic drug monitoring (TDM), and source control. METHODS: We report three new cases and review 30 literature cases (total n=33). Pooled analysis was performed for epidemiology, antimicrobial susceptibility, treatment modalities, source control, infection clearance, mortality, and neurological outcomes. A stratified analytical framework was applied to separately examine determinants of infection clearance and determinants of post-clearance survival. RESULTS: Patients were predominantly middle-aged males (mean 47 years). All infections occurred post-neurosurgery; external ventricular drainage (67%) and CSF leak (30%) were most frequent. CAZ-AVI was used in 14/33 cases (42%; 14/32, 44% among evaluable cases). Local therapy was employed in 25/32 evaluable cases (78%). Source control was performed in 28/33 (85%); among device-related cases, device removal/exchange was performed in 23/31 (74%). Any hydrocephalus occurred in 19/33 (58%), while new-onset hydrocephalus after infection requiring continued drainage or permanent diversion occurred in 5/33 (15%). Among 21 patients with evaluable neurological outcome, poor outcome (mRS ≥3 or death) occurred in 13 (62%); in the full cohort, 13/33 (39%) had documented poor outcome. CONCLUSIONS: Successful management rests on four principles: (1) definitive source control including device removal; (2) susceptibility-guided systemic/local therapy optimized by TDM; (3) immunocompromise is not a contraindication; and (4) delayed VPS placement (≥4 weeks off antibiotics). While infection control is achievable in 97%, good functional recovery remains limited.