Neuro-Infections and Stewardship Practices – A Call for Action to a Neurologist and Neurosurgeon (’NEURON AMSP’ Model)

Central nervous system (CNS) infections remain a leading cause of neurological morbidity and mortality worldwide. Bacterial meningitis, brain abscesses, and post-neurosurgical infections present high-risk clinical scenarios characterized by rapid progression, diagnostic uncertainty, and limited antimicrobial penetration across the blood–brain barrier. Despite advances in critical care, mortality from bacterial meningitis remains 10%–30% in adults, and neurologic sequelae affect up to half of survivors.[1,2] In tertiary care centers, the interplay between infection control, neurosurgical practices, and antimicrobial use forms a critical nexus in antimicrobial resistance (AMR) containment. Neurologists and neurosurgeons are increasingly recognized not only as prescribers but as stewards—those who guide diagnostics, rational therapy, and device-related infection prevention. International and national guidelines exist for meningitis, encephalitis, and perioperative prophylaxis, yet translation into daily practice remains suboptimal.[3] The Society of Antimicrobial Stewardship PractIce (SASPI)’s consensus underscores India’s need for discipline-specific stewardship frameworks to complement existing infection-control programs.[4] This editorial elaborates on the burden of neuro-infections contributing to AMR, outlines stewardship strategies tailored for neurologists and neurosurgeons, and adapts SASPI’s practical action points (’NEURON AMSP’ model) for implementation in tertiary care hospitals. Neuro-Infections Contributing to Antimicrobial Resistance and Its Concern CNS infections such as bacterial meningitis, brain abscess, ventriculitis, and post-neurosurgical infections often require prolonged and broad-spectrum antimicrobial use, creating fertile ground for resistance. Common pathogens—Streptococcus pneumoniae, Neisseria meningitidis, Staphylococcus aureus, and Acinetobacter baumannii—increasingly exhibit multidrug resistance (MDR), especially in post-surgical or intensive-care settings.[5] The emergence of carbapenem-resistant Acinetobacter and extended-spectrum β-lactamase (ESBL)-producing Enterobacterales complicates empiric therapy decisions. Diagnostic challenges exacerbate this issue. Conventional cultures fail in up to 50% of suspected CNS infections, particularly after prior antimicrobial exposure. The advent of metagenomic next-generation sequencing (mNGS) offers unprecedented breadth of pathogen detection and helps in identifying unexpected etiologies.[6] Rapid multiplex PCR panels for meningitis and encephalitis (e.g. Film Array) have been shown to shorten unnecessary acyclovir or broad-spectrum antibiotic courses by up to 2 days. Antimicrobial overuse in neurosurgical ICUs is further compounded by empiric coverage for fever, prophylaxis extended beyond 24 hours, and unindicated dual therapy. Indiscriminate continuation of broad-spectrum drugs in sterile-culture cases often promotes resistant nosocomial flora.[5] Globally, neuro-infections are also evolving in complexity due to immunosuppression, aging, and post-transplant care. Fungal meningitis and tuberculous meningitis (TBM) pose special diagnostic and therapeutic challenges, particularly in developing countries. Indian data indicate persistent mortality and prolonged hospitalization in CNS abscess and TBM cases.[2] In this context, AMR stewardship must not only target antimicrobial choice but also diagnostic timing, surgical asepsis, CSF shunt care, and interdepartmental collaboration. Neurologists and neurosurgeons, at the interface of microbiology and critical care, are optimally positioned to lead this stewardship revolution. Stewardship: neurologists and neurosurgeons as problem-solvers Stewardship in neurological infections is distinct. Unlike pulmonary or abdominal infections, where cultures are easily obtained, CNS infections rely on invasive sampling, limited fluid volumes, and high-risk empiric therapy. Here, stewardship focuses on precision and prevention. Diagnostic stewardship: Neuro-physician/surgeon should ensure that lumbar puncture or ventricular sampling is performed early, before antimicrobials, and that results are interpreted with microbiology input. Cerebrospinal fluid (CSF) and shunt aspirates are generally sterile, yet contamination during collection or processing can yield false-positive cultures, especially with skin commensals such as Coagulase-negative Staphylococci and with colonizers grown after shunt procedures. Misclassification of such isolates as pathogens leads to unwarranted prolonged intravenous therapy and fosters resistance. According to Panda et al., every culture-positive report must be interpreted in conjunction with cytology, biochemical indices, and clinical evolution to avoid treating contaminants/commensals/colonizers as pathogens.[7] This principle is central to diagnostic stewardship in neurology and neurosurgery too. Adoption of mNGS and rapid PCR panels also improves pathogen yield and guides early de-escalation.[6] Therapeutic stewardship: Empirical therapy should follow local antibiograms and guideline-driven principles.[4] Short, high-dose, CNS-penetrating regimens with early review at 48–72 hours are crucial. For resistant Gram-negatives, intraventricular or intrathecal administration of colistin or polymyxin B has shown favorable outcomes when guided by stewardship teams.[8] Novel agents such as cefiderocol demonstrate promising CSF penetration for carbapenem-resistant A. baumannii. Surgical and device stewardship: Neurosurgeons must optimize asepsis, minimize catheter duration, and prefer antibiotic-impregnated shunts, which significantly reduce shunt infection rates.[9] Strict criteria for device reinsertion and biofilm prevention form the cornerstone of surgical stewardship. Organizational and educational stewardship: Pharmacist-led antimicrobial stewardship (AMS) interventions in neurosurgical ICUs have reduced broad-spectrum antibiotic days by >25% and MDR incidence by nearly one-third.[10] Embedding stewardship rounds within neurology and neurosurgery units strengthens culture and accountability. Together, these efforts transform neurologists and neurosurgeons from mere prescribers into champions of antimicrobial governance—advancing patient safety and sustainability of therapeutic options. SASPI Practice Points for Neurologists and Neurosurgeons The SASPI provides 42 discipline-specific points applicable across tertiary hospitals in India.[4] Translating these into neurological and neurosurgical settings yields the following adapted highlights: Diagnostic optimization: Early CSF collection, molecular panel access, and multidisciplinary review of results. Antimicrobial initiation: Base empiric therapy on infection site, community vs hospital acquisition, and penetration profile. De-escalation: Review culture or molecular data within 48 hours; stop redundant agents. Duration control: Follow guideline-recommended durations (e.g. meningitis 7–14 days; brain abscess 4–6 weeks with imaging-based reassessment). Perioperative prophylaxis: Restrict to ≤24 hours for clean neurosurgical procedures.[5] Device management: Employ antibiotic-impregnated catheters; maintain sterile technique during insertion and removal.[8] Collaboration: Regular AMS meetings between neurology, neurosurgery, microbiology, and pharmacy teams. Data tracking: Maintain unit-specific antibiograms and infection trends. Education: Incorporate AMS modules in resident training and morbidity reviews. Infection prevention: Enforce hand hygiene, environmental disinfection, and vaccination (pneumococcal, influenza) for vulnerable cohorts. Special scenario: patients under the care of a neurologist and/or neurosurgeon are most of the time in prolonged critical or hospital care and might show the colonizer growth in protocol-based culture samples of tubes or lines; in these cases, right pathogen diagnostic stewardship should be practiced based on a stepwise or any innovative model.[7] These actionable steps align global evidence with local feasibility, fostering sustainable AMS practice across neuro-specialties. Conclusion Neuro-infections epitomize the delicate balance between lifesaving empiric therapy and antimicrobial restraint. While the neurologist ensures diagnostic precision, the neurosurgeon preserves asepsis and judicious device use; both share responsibility for stewardship leadership. Integration of SASPI’s practice framework provides a structured pathway to reduce resistance, shorten hospital stay, and improve outcomes in CNS infections [Box 1].Box 1: Integrated Antimicrobial Stewardship action points for neurologists and neurosurgeonsSustained collaboration between neurologists, neurosurgeons, microbiologists, and infection-control experts is vital for combating AMR. Stewardship in neuro-infections is not an adjunct—it is the core of ethical, evidence-based neurological care. Authorship Prasan Kumar Panda: Concept; writing; review of final manuscript. Saravanan Sadhasivam: Concept; writing; review of final manuscript. Ashutosh Tiwari: Concept; writing; review of final manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.