Recommended dosages of antimicrobial agents administered by the intraventricular route

Antimicrobial agent	Daily intraventricular dose
Amikacin	5 to 50 mg^*
Colistin	10 mg colistimethate sodium (CMS), which corresponds to: 125,000 international units of CMS or 4.2 mg colistin base activity (approximately)^¶
Daptomycin	2 to 5 mg^Δ
Gentamicin	1 to 2 mg^◊ in children 4 to 8 mg^◊§ in adults
Polymyxin B	2 mg in children 5 mg in adults
Quinupristin/dalfopristin	2 to 5 mg
Tobramycin	5 to 20 mg
Vancomycin	5 to 20 mg^◊§¥

There are no specific data that define the exact dose of intraventricular antimicrobial agents that should be used in cerebrospinal fluid (CSF) shunt and drain infections. Given the smaller CSF volume in infants (approximately 50 mL) compared with adults (approximately 125 to 150 mL), doses in infants should probably be decreased at least 60% or more compared to adults. Antibiotics given through the intrathecal or intraventricular route should be preservative free. UpToDate Editor's Note: Pediatric data are limited; consultation with a pediatric infectious diseases specialist is advised.

* The usual intraventricular dose is 30 mg daily.

¶ The formulation available in the United States is measured as colistin base activity. The total daily dose can be administered as one daily dose or divided into two doses given every 12 hours.

Δ One study used 10 mg every day for 2 days and then 10 mg every 48 hours. Another study used 5 mg or 10 mg every 72 hours. Data are based on isolated case reports.

◊ Recommendations for frequency of administration based on external ventricular drain output over 24 hours as follows:

<50 mL/24 hours: Every third day.
50 to 100 mL/24 hours: Every second day.
100 to 150 mL/24 hours: Once daily.
150 to 200 mL/24 hours: Increase the dosage by 5 mg of vancomycin and 1 mg of gentamicin and give once daily.
200 to 250 mL/24 hours: Increase the dosage by 10 mg of vancomycin and 2 mg of gentamicin and give once daily.

§ Dosage recommendations in adults based on ventricle size/volume as follows:

Slit ventricles: 5 mg vancomycin and 2 mg gentamicin.
Normal size: 10 mg vancomycin and 3 mg gentamicin.
Enlarged ventricles: 15 to 20 mg vancomycin and 4 to 5 mg gentamicin.

¥ Most studies used a 10 mg or 20 mg dose.

Reproduced from: Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017. By permission of Oxford University Press on behalf of the Infectious Diseases Society of America. Copyright © 2017. https://www.idsociety.org/practice-guideline/healthcare-associated-ventriculitis-and-meningitis/ (Accessed on March 29, 2023).

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Recommended dosages of antimicrobial agents administered by the intraventricular route