Shunt implantation: reducing the incidence of shunt infection

Risk factors and epidemiology of pediatric ventriculoperitoneal shunt infection

BACKGROUND

The aim of this study was to identify independent risk factors for cerebrospinal fluid shunt infection.

METHODS

The medical records of all patients aged 0-18 years who underwent shunt-related surgery for the treatment of hydrocephalus at the present institution between January 1996 and December 2015 were reviewed. For each case, two randomly selected controls with no shunt infection, matched for year of surgery, were chosen. Demographic clinical and microbiological data were abstracted.

RESULTS

A total of 1,570 shunt-related procedures met the inclusion criteria, yielding 68 infections (in 63 patients). The control group consisted of 132 infection-free patients. The average annual infection rate was 4.2% cases per year. The median time between shunt procedures to infection was 19 days (range, 1-2,181). On multivariate analysis, risk factors associated with increased risk for developing an infection included a history of two or more previous revisions (OR, 4.8; 95%CI: 1.5-15.9); and age <5 years (OR, 4.5; 95%CI 1.5-13.4). A neoplastic etiology for hydrocephalus was found to be a protective factor for shunt infection (P = 0.001).

CONCLUSIONS

A history of shunt revision was the most significant risk factor in the development of subsequent shunt infection. Age >5 years was a protective factor. Future efforts should focus on modalities to optimize revision procedures and reduce the risk of subsequent infection.

Gastrostomy tube placement increases the risk of ventriculoperitoneal shunt infection: a multiinstitutional study

OBJECTIVE

Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions.

METHODS

A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized.

RESULTS

The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07-4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04-3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1-2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection.

CONCLUSIONS

Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.

Risk Factors of Delayed Intracranial Hemorrhage Following Ventriculoperitoneal Shunt

Objective

Placement of a ventriculoperitoneal (VP) shunt is a common neurosurgical procedure for cerebrospinal fluid diversion. A rare complication is delayed intracranial hemorrhage (ICH) secondary to VP shunting, and only a few patients with this complication have been reported. We investigate the incidence and risk factors of delayed ICH development following VP shunt placement.

Methods

Over an 11-year period, 167 patients received a VP shunt for hydrocephalus, and of these, 138 patients were eligible for this study. All medical records and computed tomography scans obtained within 48 h after the operation and at postoperative day 7 were reviewed. The risk factors of developing delayed ICH (≥48 hr after VP shunt placement) were analyzed according to the demographic data, including sex and age, original intracranial lesions, co-morbid diseases, and laboratory findings.

Results

Delayed ICH following VP shunt placement developed in 34 (24.6%) of the 138 patients. Risk factors for developing delayed ICH were age (p=0.037) and the partial thromboplastin time (PTT) (p=0.032). Intraventricular hemorrhage after VP shunting was the most common complication, occurring in 16 cases. Hemorrhagic volume was <1 mL in 28 cases and >1 mL in 6 cases.

Conclusion

This study suggests that old age and delayed PTT are major risk factors for developing delayed ICH following VP shunting. Additionally, delayed ICH after VP shunting commonly occurs even when most patients are asymptomatic. Therefore, extra care should be taken to observe and follow-up with patients who have undergone VP shunt placement.

Shunt infections: a review and analysis of a personal series

INTRODUCTION AND PURPOSE

CSF diversion shunts are notoriously prone to complications. The most difficult to manage among them is shunt infection, which warrants a prolonged hospital stay. The aim of this paper is to review the pattern of infections, the pathology, and management of shunt infections with special reference to a tertiary pediatric center in a developing country.

MATERIALS AND METHODS

This is a review of shunt infections in general and a retrospective study of all cases operated in the hospital from 2000 to 2015.

RESULTS

The authors analyze the data and try to discern patterns, which may enable newer interventions to treat as well as decrease the burden of shunt infections in the future.

CONCLUSION

It is difficult to determine the true incidence of shunt infections as there is no definition of what constitutes a shunt infection. There are no standardized international guidelines as to how to deal with an infected shunt. Though the ability to treat shunt infection has improved and the incidence of shunt infection has decreased over time, there is still no consensus on the best way to manage it. The prevention is predominantly based on common sense and has helped but a more scientific algorithm is the need of the hour.

Analysis of Codman microcerebrospinal fluid shunt

INTRODUCTION

Ventriculo-peritoneal cerebrospinal fluid (CSF) shunt is the most common method of treating pediatric hydrocephalus. The Codman microadjustable valve (CMAV) is a CSF shunt constructed for children. The objective of the study was (a) to analyze complications after insertion of a CMAV shunt in hydrocephalic children, (b) to analyze complications after replacing a CMAV by an adult-type Codman Hakim adjustable valve shunt (CHAV), and to (c) analyze the in vitro characteristics of the CMAV shunt and correlate the findings with the clinical performance of the shunt.

METHODS

A retrospective study analyzed a cohort of hydrocephalic children who had received a CMAV shunt and later replaced by a CHAV shunt. We report on the complications that resulted from replacing the CMAV with the CHAV. We tested six CMAV shunts with or without an antisiphon device (ASD) in which opening pressure, resistance, sensitivity to abdominal pressure, ASD position dependency, and function were determined. The test results were correlated with the clinical performance of the shunt in the retrospective study.

RESULTS

Thirty-seven children (19 boys, 18 girls) were identified. Within the first month after shunt placement, a total of 10 patients (27%) developed complications including infections, hygromas, and shunt dysfunction. Shunt survival varied from 1 week to 145 months. Over the 10-year follow-up period, 13 children had their shunts replaced, six of them with a CHAV without any further complications. A bench test of the CMAV was done to test whether the opening pressure was in agreement with the manufacturer's specifications. Our results were generally in agreement with specifications stated by the manufacturer.

CONCLUSION

Replacing a CMAV with a CHAV was well tolerated by the patients. Bench test results were generally in agreement with manufacturers specifications. Replacing a CMAV with a CHAV in pediatric hydrocephalus patients can be accomplished safely.

Shunt revision rates in myelomeningocele patients in the first year of life: a retrospective study of 52 patients

PURPOSE

Shunt placement indications are stringent and require confirmation of clinical and radiological evidence of hydrocephalus (HC). The aim of this study was to determine the rate of shunting and discuss the outcome in the first year of life in patients with myelomeningocele (MMC) on the basis of review of the literature.

METHODS

All patients who underwent postnatal repair of MMC at our institution between March 2014 and March 2015 were evaluated. Patients were only included if they underwent both MMC repair and ventriculoperitoneal (VP) shunt insertion at our institution and were followed up for at least 12 months. The mean ages for repair of MMC, MMC levels, timing of VP shunt placement, shunt revisions, and causes of shunt revisions were documented.

RESULTS

Fifty-two patients with MMC were included in this study. The average gestational age at birth was 38 weeks. The level of MMC was thoracolumbar in 13 cases, 11 times lumbar, 21 times lumbosacral, and 7 times sacral. Thirty-one patients (59.61%) suffered from hydrocephalus and required placement of a shunt. When we evaluate the lesion levels of patients who require shunting, 13 cases were thoracolumbar, 6 cases were lumbar, and 11 cases were lumbosacral. None of the sacral cases needed VP shunt. Seven patients (13.4%) had shunt revision within the first year of life. The cause of shunt revision was wound problem in one patient (1.9%), underdrainage in two patients (3.8%), infection in three patients (5.7%), and mechanical obstruction in another one patient (1.9%).

CONCLUSION

MMC closure and management of the associated HC are one of the most basic, but never simple, legs of the pediatric neurosurgery around the world. As clinicians and neurosurgeons, we are obligated to analyze recent evidences and evaluate present approaches to achieve optimization in this subject until further technologies or approaches became more advantageous for our patients.

A standardized protocol to reduce pediatric baclofen pump infections: a quality improvement initiative

OBJECTIVE Intrathecal baclofen pumps are generally placed in children for the treatment of spasticity and dystonia. Use of implants in this pediatric population with comorbidities is reported to have a high risk of complications and infections. With the aim of reducing baclofen pump-related infections, a quality improvement project was instituted at the authors' institution. METHODS A workflow paradigm unique to baclofen pump implantation aimed at decreasing implant-related infections was implemented. All baclofen pump operations performed at the authors' institution between August 2012 and June 2016 were reviewed. An infection prevention protocol was created and implemented in August 2014 based on a literature review and the consensus opinion of the pediatric neurosurgeons in the group. Compliance with the prevention bundle was tracked. Case outcomes before and after implementation of the protocol with a minimum of 3 months of follow-up were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the association of the steps in the prevention bundle with infection and complication outcomes. RESULTS A total of 128 baclofen pump surgeries were performed (64 preprotocol and 64 postprotocol). The patient age range was 3 to 27 years. The overall compliance rate with the infection prevention bundle was 82%. The pre- and postimplementation infection rates were 12.5% and 6.3%, respectively (p = 0.225). The total pre- and postimplementation complication rates were 23.4% and 9.4%, respectively (p = 0.032). The absolute and relative risk reductions for infections were 6.3% (95% CI 3.8%-16.3%) and 50%, respectively; for complications, the absolute and relative risk reductions were 14.1% (95% CI 1.5%-26.7%) and 60%, respectively. CONCLUSIONS The total complication rate following intrathecal baclofen pump surgery was significantly lower after implementation of the quality improvement protocol. This study is an example of using checklist standardization to diminish special cause variability.

Topical vancomycin reduces the cerebrospinal fluid shunt infection rate: A retrospective cohort study

Object

Despite many efforts at reduction, cerebrospinal fluid (CSF) shunt infections are a major cause of morbidity in shunt surgery, occurring in 5–15% of cases. To attempt to reduce the shunt infection rate at our institution, we added topical vancomycin (intrashunt and perishunt) to our existing shunt infection prevention protocol in 2012.

Methods

We performed a retrospective cohort study comparing all shunted patients in January 2010 to December 2011 without vancomycin (control group, 263 procedures) to all patients who underwent shunt surgery between April 2012 and December 2015 with vancomycin (intervention group, 499 procedures).

Results

The overall shunt infection rate significantly decreased from 6.8% (control group) to 3.0% (intervention group) (p = 0.023, absolute risk reduction 3.8%, relative risk reduction 56%). Multivariate logistic regression analysis confirmed that the addition of topical vancomycin showed that cases treated under a protocol of topical vancomycin were associated with a decreased shunt infection rate (odds ratio [OR] 0.49 95% CI 0.25–0.998; p = 0.049). Age < 1 year was associated with an increased risk of infection (OR) 4.41, 95% CI 2,10–9,26; p = 0.001). Time from surgery to infection was significantly prolonged in the intervention group (p = 0.001).

Conclusion

Adding intraoperative vancomycin to a shunt infection prevention protocol significantly reduces CSF shunt infection rate.

The Impact of a Pediatric Shunt Surgery Checklist on Infection Rate at a Single Institution

BACKGROUND

Shunt infections remain a significant challenge in pediatric neurosurgery. Numerous surgical checklists have been introduced to reduce infection rates.

OBJECTIVE

To introduce an evidence-based shunt surgery checklist and its impact on our shunt infection rate.

METHODS

Between January 1, 2008 and December 31, 2015, pediatric patients who underwent shunt surgery at our institution were indexed in a prospectively maintained database. All definitive shunt procedures were included. Shunt infection was defined according to the Center for Disease Control and Prevention's National Hospital Safety Network surveillance definition for surgical site infection. Clinical and procedural variables were abstracted per procedure. Infection data were compared for the 4 year before and 4 year after protocol implementation. Compliance was calculated from retrospective review of our checklists.

RESULTS

Over the 8-year study period, 1813 procedures met inclusion criteria with a total of 37 shunt infections (2%). Prechecklist (2008-2011) infection rate was 3.03% (28/924) and decreased to 1.01% (9/889; P = .003) postchecklist (2012-2015), representing an absolute risk reduction of 2.02% and relative risk reduction of 66.6%. One shunt infection was prevented for every 50 times the checklist was used. Those patients who developed an infection after protocol implementation were younger (0.95 years vs 3.40 years (P = .027)), but there were no other clinical or procedural variables, including time to infection, that were significantly different between the cohorts. Average compliance rate among required checklist components was 97% (range 85%-100%).

CONCLUSION

Shunt surgery checklist implementation correlated with lower infection rates that persisted in the 4 years after implementation.

Cerebrospinal Fluid Shunting Complications in Children

Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Forty years of shunt surgery at Rigshospitalet, Denmark: a retrospective study comparing past and present rates and causes of revision and infection

OBJECTIVE

The objective of this study is to review our experience of shunt surgery by investigating 40 years of development in terms of rates of revision and infection, shunt survival and risk factors.

DESIGN AND PARTICIPANTS

Medical records and operative reports were reviewed retrospectively for all patients who underwent primary shunt surgery at our department in the years 2010 to 2012. All results were compared with a previous study from our department. A mixed population consisting of 434 patients was included. Adults (≥15 years) accounted for 89.9% of all patients and the mean follow-up time was 1.71 years.

RESULTS

Overall, 42.6% had a revision of which 65.4% fell within 6 months postoperatively. Low age, high-risk diagnoses and less severe brain injury were associated with a higher risk of revision. One and 5-year shunt survival probabilities were 66.2% (61.5-70.9) and 48.0% (41.1-54.9). Within 4 weeks postoperatively, 3.2% had an infection and overall infection rate was 5.5%. Short duration of surgery and the use of antibiotic prophylaxis were associated with a lower risk of infection. The most frequent causes of revision were valve defects (18.4%) and proximal defects or obstructions (15.7%). Compared to the previous study, no convincing improvement was found with regard to the revision rate (42.6% vs 48.3%, p 0.060) or overall infection rate (5.5% vs 7.4%, p 0.261).

CONCLUSIONS

Regardless of changes in patient demographics, techniques and equipment, risk of revision and infection still constitutes a major challenge in shunt surgery. The absence of convincing improvements calls for more studies concerning strategies to reduce complications.

Long-term mortality rates in pediatric hydrocephalus-a retrospective single-center study

PURPOSE

Very long-term follow-up and outcome are rare for pediatric patients with hydrocephalus and shunt operations. The aim of this study was to determine the long-term mortality rates in these patients.

METHODS

Pediatric patients with first shunt operation between 1982 and 1992 were included. For each patient, time and cause of death were determined. Further, patients with first operation from 1982 to 1987 were compared to those first operated from 1988 to 1992.

RESULTS

One-hundred thirty-seven patients were included. Etiologies of hydrocephalus were intraventricular hemorrhage (31.4 %), meningomyelocele (25.5 %), postinfectious (11.7 %), congenital (10.2 %), posterior fossa cyst (8.8 %), aqueductal stenosis (8 %), and others (4.4 %). Overall, 53 patients (38.7 %) died. The percentage of patients surviving 1, 2, 10, and 20 years after first operation were 82.6, 73.6, 69.4, and 65.3 %, respectively. In 23 patients, the cause of death was related to shunt treatment: shunt infection was diagnosed in 18 and acute shunt dysfunction in 5 patients. Mortality was considerably higher for patients with their first operation in time period 1982-1987 compared to time period 1988-1992 (51 versus 25 %). The reduction of mortality was mainly due to an increased survival after shunt infection. Eighty-seven patients survived more than 20 years after initial shunt operation. Of those long-term survivors, three (3.4 %) patients died 22-24 years after first operation.

CONCLUSION

Mortality in hydrocephalic pediatric patients is high especially in the first postoperative years but is even significant in adult patients with pediatric hydrocephalus. As deaths occur even after 20 years, routine follow-up of long-term survivors remains necessary.

Predicting ventriculoperitoneal shunt infection in children with hydrocephalus using artificial neural network

OBJECTIVES

The relationships between shunt infection and predictive factors have not been previously investigated using Artificial Neural Network (ANN) model. The aim of this study was to develop an ANN model to predict shunt infection in a group of children with shunted hydrocephalus.

MATERIALS AND METHODS

Among more than 800 ventriculoperitoneal shunt procedures which had been performed between April 2000 and April 2011, 68 patients with shunt infection and 80 controls that fulfilled a set of meticulous inclusion/exclusion criteria were consecutively enrolled. Univariate analysis was performed for a long list of risk factors, and those with p value < 0.2 were used to create ANN and logistic regression (LR) models.

RESULTS

Five variables including birth weight, age at the first shunting, shunt revision, prematurity, and myelomeningocele were significantly associated with shunt infection via univariate analysis, and two other variables (intraventricular hemorrhage and coincided infections) had a p value of less than 0.2. Using these seven input variables, ANN and LR models predicted shunt infection with an accuracy of 83.1 % (AUC; 91.98 %, 95 % CI) and 55.7 % (AUC; 76.5, 95 % CI), respectively. The contribution of the factors in the predictive performance of ANN in descending order was history of shunt revision, low birth weight (under 2000 g), history of prematurity, the age at the first shunt procedure, history of intraventricular hemorrhage, history of myelomeningocele, and coinfection.

CONCLUSION

The findings show that artificial neural networks can predict shunt infection with a high level of accuracy in children with shunted hydrocephalus. Also, the contribution of different risk factors in the prediction of shunt infection can be determined using the trained network.

Prevention of infection by antibiotic-impregnated shunts after pediatric hydrocephalus treatment: A single center, retrospective study in China

OBJECTIVE

To investigate infection prevention by antibiotic-impregnated shunts (AIS) relative to conventional ones after pediatric hydrocephalus treatment.

METHODS

This single center, retrospective analysis comprised 807 consecutive pediatric cases of hydrocephalus shunting performed by the same neurosurgeon between January 2001 and February 2013. Conventional and AIS catheters were used in 303 and 504 cases, respectively. Study outcomes were infection rates at 6 months (primary), and at 1 month and between 1 and 6 months (secondary). An infant (<1year) subgroup was also analyzed.

RESULTS

The AIS relative to the conventional catheter group had significantly lower infection rates at 6 months (1.98% [10/504] vs. 5.95% [18/303], two-tailed p=0.0046; central nervous system: 60% and 55.56%; abdominal: 20% and 27.77%; wound: 20% and 16.67%, respectively) and 1 month (0.19% [1/504] vs. 2.65% [8/303], p=0.0023, respectively), but statistically similar rates between 1 and 6 months (1.79% [9/504] vs. 3.30% [10/303], p=0.2296, respectively). In the infant subgroup, AIS application was also associated with reduction in shunt infection (1.49% [7/470] vs. 3.76% [10/266], p=0.0489, respectively).

CONCLUSION

AIS as compared to conventional catheter use appears to lower infection risk at 6 months, mainly during the first month, after hydrocephalus therapy in children.

Evaluation of intraoperative glove change in prevention of postoperative cerebrospinal fluid shunt infections, and the predictors of shunt infection

BACKGROUND

We have previously suggested that surgical gloves could be a possible means for transferring microorganisms from skin flora to shunt material during surgery. The objectives of this study were to examine (1) whether the rate of shunt infections was reduced after introducing intraoperative glove change before handling the shunt material; (2) clinical presentation of shunt infections, microbiological data, and treatment management; and (3) predictors of shunt infections.

METHODS

A retrospective study of 432 shunt operations in 295 adults was undertaken over a 7-year period. Study population consisted of two groups: Group A without intraoperative glove change (2003-2006), and Group B with change of the outer pair of the initial double gloves before handling the shunt material (2006-2009). The results were compared at 6- and 12-month postoperatively. A binary logistic regression was performed to determine predictors of shunt infections.

RESULTS

Overall, 46 (10.6%) infection episodes occurred in 40 (13.6%) patients. Main symptoms were fever, abdominal pain and altered mental status. Propionibacterium acnes was the frequently isolated microorganism, followed by Staphylococcus species. The infection rate was reduced only moderately from 11.8% in Group A to 9.8% in Group B (p = .472). Patients with subarachnoid haemorrhage were more likely to experience shunt infections (17.9%), compared to patients with normal pressure hydrocephalus (5.9%). An increased likelihood of shunt infections for the increased number of subsequent shunt revisions (p = .030) and a trend towards prior history of shunt infections (p = .118) was seen. After adjusting for various covariates, a decreased likelihood of shunt infections for intraoperative glove change was seen at 6-month follow-up for first-time shunt insertion (p = .050).

CONCLUSION

Intraoperative glove change does not significantly reduce the risk of shunt infection. However, it seems to reduce the infection rate within 6 months in patients undergoing first-time shunt insertion only.

Serum and Cerebrospinal Fluid Vancomycin and Gentamicin Concentrations during Ventriculoperitoneal Shunt Surgery: An Observational Study

Background:

Ventriculoperitoneal shunts become infected predominantly during surgery. Optimal antibiotic prophylaxis during cerebrospinal fluid (CSF) shunt surgery has not been fully determined.

Objective:

To quantitate the concentrations of vancomycin and gentamicin in the serum and CSF during 100 ventriculoperitoneal shunt surgeries at the time of shunt manipulation.

Design:

Descriptive, prospective, observational study with a 27- to 76-month postoperative follow-up period range.

Setting:

University hospital.

Patients:

Eighty-three hydrocephalic patients ranging from premature to adult ages.

Interventions:

Intraoperatively, children received intravenous vancomycin 15 mg/kg/dose and gentamicin 2.5 mg/kg/dose; adults received vancomycin 1 g/dose and gentamicin 1.5 mg/kg/dose. Antibiotics were continued for 24 hours postoperatively, with dosage and schedule adjusted for age. Antibiotic serum and CSF concentrations were sampled one hour after infusion, and measured via fluorescence polarization immunoassay. Meticulous surgical infection control measures were followed.

Main Outcome Measures:

Correlation of intraoperative serum and CSF antibiotic concentrations with postoperative infection rate.

Results:

Intraoperative vancomycin serum concentrations ranged from 10.8 to 53.8 μg/mL (28.0 ± 9.5 μg/mL, mean ± SD). Intraoperative gentamicin serum concentrations ranged from 3.9 to 9.4 μg/mL (4.8 ± 2.0 μg/mL). In all surgeries, intraoperative CSF vancomycin and gentamicin concentrations were low (vancomycin <5 μg/mL, gentamicin <2 μg/mL). The infection rate among surgeries was 2.0%, and the infection rate among patients was 2.4%. Two shunt infections occurred, one with Candida albicans and one with Citrobacter freundii.

Conclusions:

Serum concentrations of vancomycin and gentamicin were above the minimum inhibitory concentrations for likely pathogens in 84% and 74% of surgeries, respectively. Intraoperative bacteriostatic and bactericidal CSF antibiotic concentrations may not be necessary to achieve a low postoperative shunt infection rate. Larger confirmatory studies are needed.

Ventriculoatrial Shunts in Adults, Incidence of Infection, and Significant Risk Factors: A Single-Center Experience

BACKGROUND

In recent years, the number of ventriculoatrial (VA) shunt insertions has decreased worldwide, the major cause being the risk of shunt infection. VA shunts remain as an alternative option to ventriculoperitoneal shunts. We describe our 10-year experience with VA shunts by analyzing the incidence of shunt infections and predisposing cofactors.

METHODS

During a median follow-up of 15.3 months, 259 shunt insertions, performed on 255 patients, were analyzed. The infection rate was calculated and the predisposing cofactors age, gender, cause of the hydrocephalus, previous external ventricle drainage, antibiotic-impregnated catheters, the number of revisions, the educational level of the surgeons, and the duration of the operations were analyzed. Two observation times were stratified.

RESULTS

We found overall infections in 18 patients (7.1%), 16 deep infections (6.3%) including 1 shunt nephritis (0.4%) and 2 superficial infections (0.8%). Wound dehiscence occurred in 17 patients (6. 6%). Analyzing follow-up time, the infection rate was 3.65% (95% confidence interval, 0.9%-5.9%) at survival time 1, 3.38% (95% confidence interval, 1.1%-6.2%) at survival time 2. In the first 6 months, 95% of patients were free of infection. Only the number of revision procedures was associated with the number of infections (P value < 0.0005).

CONCLUSIONS

In our patient cohort, the infection rate related to VA shunt insertion is low; the only statistically significant risk factor was the number of revisions. If the VA shunt is applied following a standardized protocol, the infection risk does not represent an argument for reluctance towards the VA draining concept.

Hydrogel-coated ventricular catheters for high-risk patients receiving ventricular peritoneum shunt

Shunt infection is a morbid complication of cerebrospinal fluid (CSF) shunting. The catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter-related CSF infection.A retrospective study compared the occurrence of CSF infection related to use of either standard silastic catheters or hydrogel-coated ventricular catheters (Bioglide, Medtronic). The enrolment was available to neurosurgery patients undergoing shunt surgery from October 2012 to 2015 in two centers. The follow-up period was more than months.A total of 78 patients were included in the study. In 33 patients 35-cm hydrogel-coated ventricular peritoneum shunts (VPS) were used, and in remaining 45 patients 35-cm standard silastic VPS catheters were used. Infection occurred in 14 (17.9%) patients, including definite VPS-related CSF infection in 6 patients (7.7%) and probable infection in remaining 8 patients (10.3%). There was a significant difference found in patients with total infection between the two groups [RR (95% CI); 0.200 (0.050-0.803), P = 0.014]. Analysis of Kaplan-Meier curve estimates indicated significant statistical difference between the two catheter types in duration (log rank = 4.204, P < 0.05). Significant statistical differences were also found in the subgroups including previous CSF infection within 1 month (log rank = 4.391, P = 0.04), conversion of external ventricular drains to shunt (Log Rank = 4.520, P = 0.03), and hospital stay >1 month (log rank = 5.252, P = 0.02). There was no difference found between the two groups of the patients with other infections within 1 month. The follow-up period was of 36 months.The hydrogel-coated catheter is a safe and related to lower infection rates for high-risk patients who underwent shunt surgery.

Is capsulectomy a feasible and useful measure in internal pulse generator replacement procedures? A technical note on the use of the PEAK PlasmaBlade(TM)

BACKGROUND

Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of extension cable damage or IPG pocket infection, it can dramatically affect a patient's quality of life. Higher risk of infection has been reported after IPG replacement procedures rather than after primary deep brain stimulation lead implantation, and some authors suggested that the IPG pocket capsule could play a pivotal role in causing it. In this technical note we present a capsulectomy technique adopted in IPG replacement procedures.

METHODS

Between July and October 2015, we carried out ten outpatient IPG replacement procedures at the chest and abdomen under local anesthesia for battery depletion using the PEAK PlasmaBlade(TM). All patients were followed for at least 2 months to rule out any hardware malfunction and infection.

RESULTS

All ten procedures were uneventful. No extension cable damage occurred. No IPG pocket infection occurred, also not in the follow-up. Mean surgical time was 30 min.

CONCLUSIONS

Complete capsulectomy is not feasible with basic surgical instruments, and the PEAK PlasmaBlade(TM) pencil appears to be a helpful tool in carrying out the procedure.

Outcome of ventriculoperitoneal shunt surgery, without prior placement of external ventricular drain in Grades III and IV patients of tubercular meningitis with hydrocephalus: A single institution's experience in the pediatric population and review of literature

OBJECTIVE

Hydrocephalus is a most common complication of tubercular meningitis (TBM). Relieving hydrocephalus by ventriculoperitoneal shunt (VPS) placement has been considered beneficial in patient in Palur Grades II or III. The role of VPS placement in those of Grades III and IV is controversial, and general tendency is to avoid its use. Some authors have suggested that patient in Grades III and IV should receive a shunt only if their condition improves with a trial placement of external ventricular drain (EVD). However, recent studies suggest that VPS may be undertaken without the trial of an EVD. Our study prospectively evaluates the role of direct VPS placement in patient in Grades III and IV TBM with hydrocephalus (TBMH).

MATERIALS AND METHODS

This study was carried out on 50 consecutive pediatric patients of TBMH in Palur Grades III and IV from July 2013 to December 2014 in R.N.T. Medical College and M.B. Hospital, Udaipur, Rajasthan. All patients underwent direct VPS placement, without prior placement of EVD. The outcome was assessed at the end of 3 months using Glasgow Outcome Score.

RESULTS

The mean age of patients was 3.25 years (range, 3 months-14 years). Forty (80%) patients were in Grade III, and 10 (20%) were in Grade IV. Good outcome and mortality in Grade IV patients were 30% (3/10) and 10% (1/10), respectively; whereas in Grade III patients, it was 77.5% (31/40) and 0% (0/40), respectively. Twenty-five patients presented with focal neurological deficit at admission, which persisted in only 14 patients at 3 months follow-up. VPS-related complications were observed in 5 (10%) patients.

CONCLUSIONS

This study demonstrates that direct VPS surgery could improve the outcome of Grades III and IV TBMH. Despite poor grade at admission, 80% patients in Grade III and 20% patients in Grade IV had a good outcome at 3 months follow-up. Direct VPS placement is a safe and effective option even in a patient in Grades III and IV grade TBMH with a low complication rate.

Long-term survival rates of gravity-assisted, adjustable differential pressure valves in infants with hydrocephalus

OBJECTIVE The use of adjustable differential pressure valves with gravity-assisted units in shunt therapy of children with hydrocephalus was reported to be feasible and promising as a way to avoid chronic overdrainage. In this single-center study, the authors' experiences in infants, who have higher rates of shunt complications, are presented. METHODS All data were collected from a cohort of infants (93 patients [37 girls and 56 boys], less than 1 year of age [mean age 4.1 ± 3.1 months]) who received their first adjustable pressure hydrocephalus shunt as either a primary or secondary implant between May 2007 and April 2012. Rates of valve and shunt failure were recorded for a total of 85 months until the end of the observation period in May 2014. RESULTS During a follow-up of 54.2 ± 15.9 months (range 26-85 months), the Kaplan-Meier rate of shunt survival was 69.2% at 1 year and 34.1% at 85 months; the Kaplan-Meier rate of valve survival was 77.8% at 1 year and 56% at 85 months. Survival rates of the shunt were significantly inferior if the patients had previous shunt surgery. During follow-up, 44 valves were exchanged in cases of infection (n = 19), occlusion (n = 14), dysfunction of the adjustment unit (n = 10), or to change the gravitational unit (n = 1). CONCLUSIONS Although a higher shunt complication rate is observed in infant populations compared with older children, reasonable survival rates demonstrate the feasibility of using this sophisticated valve technology. The gravitational unit of this valve is well tolerated and its adjustability offers the flexible application of opening pressure in an unpredictable cohort of patients. This may adequately address overdrainage-related complications from early in treatment.

A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection

OBJECT In a previous report by the same research group (Kestle et al., 2011), compliance with an 11-step protocol was shown to reduce CSF shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. METHODS The new protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Procedures performed up to September 30, 2013, were included (21 months). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 1935 procedures were performed on 1670 patients at 8 HCRN centers. The overall infection rate was 6.0% (95% CI 5.1%-7.2%). Procedure-specific infection rates varied (insertion 5.0%, revision 5.4%, insertion after EVD 8.3%, and insertion after treatment of infection 12.6%). Full compliance with the protocol occurred in 77% of procedures. The infection rate was 5.0% after compliant procedures and 8.7% after noncompliant procedures (p = 0.005). The infection rate when using this new protocol (6.0%, 95% CI 5.1%-7.2%) was similar to the infection rate observed using the authors' old protocol (5.7%, 95% CI 4.6%-7.0%). CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRN centers had a lower infection rate than noncompliant procedures. Implementation of the new protocol (including AICs) was associated with a 6.0% infection rate, similar to the infection rate of 5.7% from the authors' previously reported protocol. Based on the current data, the role of AICs compared with other infection prevention measures is unclear.

Ventriculosternal Shunting for the Management of Hydrocephalus: Case Report of A Novel Technique

BACKGROUND

Conventional cerebrospinal fluid diversion such as ventriculoperitoneal or ventriculoatrial shunting for the management of hydrocephalus is one of the commonest neurosurgical procedures. However, in selected patients, surgical options are limited when relative contraindications for these operations exist. A patient who underwent ventriculosternal shunting, a novel procedure, is presented with durable and successful outcomes.

OBJECTIVE

To demonstrate the feasibility, durability, and safety of ventriculosternal shunting for the management of hydrocephalus.

METHODS

A patient with end-stage renal failure and heart failure with recurrent pleural effusion suffered from post-subarachnoid hemorrhage communicating hydrocephalus. Because of the need for continuous ambulatory peritoneal dialysis and the risk of introducing excessive cardiac preloading, conventional shunting was relatively contraindicated. Ventriculosternal shunting was performed by adopting the cancellous matrix of the sternum as the anatomic receptacle for intraosseous cerebrospinal fluid absorption. After placement of the ventricular catheter in the usual manner, the distal end was inserted into the sternum.

RESULTS

There was demonstrable clinical and radiological improvement in hydrocephalus by ventriculosternal shunting. Cerebrospinal fluid intraosseous absorption by this novel procedure translated into both physical and cognitive recovery. The procedure was tolerable, effective, and durable, with the patient suffering no complications 3 years after the procedure.

CONCLUSION

Ventriculosternal shunting for the management of hydrocephalus is a feasible, safe, and durable surgical treatment option for selected patients when conventional procedures are contraindicated.

Autologous Skull Bone Flap Sterilization After Decompressive Craniectomy: An Update

OBJECTIVE

To report new results with ethylene oxide sterilization and new experiences with autogenous bone flaps autoclaved at a high or low temperature for preservation of a bone flap after decompressive craniectomy.

METHODS

In 45 patients who underwent a decompressive craniectomy, we determined bone flap preservation with ethylene oxide and with high- or low-temperature autoclave sterilization.

RESULTS

The bone flap was repositioned after a mean of 10 weeks in the ethylene oxide group and after 6 weeks in the other sterilization groups. A bone flap infection developed in 1 patient (2%), which required removal and subsequent methyl methacrylate cranioplasty. In 1 child, the bone flap had partially reabsorbed after 12 months. In all other patients, esthetic results were good after an average follow-up of 42 months. At follow-up, computed tomography or magnetic resonance imaging of the bone flap showed preservation of structural features with apparent fusion and revitalization at the bone flap margins.

CONCLUSIONS

Ethylene oxide and high- or low-temperature autoclave bone sterilization techniques for the preservation of autologous bone flaps after decompressive craniectomy were safe, rapid, and inexpensive.

Antibiotic prophylaxis for shunt surgery of children: a systematic review

OBJECTIVE

The object of this study was to evaluate the clinical effectiveness of antibiotic prophylaxis in children who underwent placement of intracranial ventricular shunts.

METHODS

In this paper, the authors report a systematic review and meta-analysis of infection rate for pediatric shunt implantation surgery. Randomized or non-randomized controlled trials for comparing the use of prophylactic antibiotics in intracranial ventricular shunt procedures with placebo or no antibiotics were included in the review.

RESULTS

Seven published reports of eligible studies involving 694 participants meet the inclusion criteria. Compared with the control group, antibiotic prophylaxis had made a significant difference in infection rate (RR = 0.59, 95% CI = 0.38, 0.90, P < 0.05).

CONCLUSION

Although current evidence demonstrates that antibiotic prophylaxis can lead to a significant reduction of the infection rate of shunt surgery, more evidence from advanced multi-center studies is needed to provide instruction for the use of prophylactic antibiotics.

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

OBJECT

The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.

METHODS

This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.

RESULTS

A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively).

CONCLUSIONS

This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants

PURPOSE

The incidence of ventriculoperitoneal (VP) shunt infection accounts for about 5-15%, but it can rise up to 70% in specific high-risk subgroups. Antibiotic-impregnated catheters (AICs) have been designed to reduce shunt infections, but reports on their efficacy are discordant, especially in young children. The aim of this study is to assess, for the first time, the efficacy of AICs in newborns and infants at very high risk for shunt infection.

METHODS

We reviewed the medical records of newborns and infants treated with a VP shunt for newly diagnosed hydrocephalus. Patients were divided in two groups: Group A was composed by children who received AICs, whereas Group B included children implanted with standard silicone catheters (non-AICs). We compared the shunt infection rate in both groups, and analyzed differences in specific high-risk subgroups (preterm newborns, children with posthemorrhagic or postinfective hydrocephalus, and children with a previous external ventricular drainage).

RESULTS

Forty eight children younger than 1 year old were included in our study. Twenty two patients were implanted with an AIC, whereas 26 patients received a standard silicone catheter. The follow-up was at least 1 year (mean 8 ± 3 years). The overall infection rate decreased from 34% in non-AIC group to 9 % in the AIC group. Moreover, AICs showed to have a protective effect against shunt infections in all the specific high-risk subgroups analyzed.

CONCLUSIONS

This study demonstrates for the first time that AICs are effective in reducing VP shunt infection in high-risk pediatric patients younger than 1 year old.

A Retrospective Analysis of Ventriculoperitoneal Shunt Revision Cases of a Single Institute

Objective

Ventriculoperitoneal (VP) shunt complication is a major obstacle in the management of hydrocephalus. To study the differences of VP shunt complications between children and adults, we analyzed shunt revision surgery performed at our hospital during the past 10 years.

Methods

Patients who had undergone shunt revision surgery from January 2001 to December 2010 were evaluated retrospectively by chart review about age distribution, etiology of hydrocephalus, and causes of revision. Patients were grouped into below and above 20 years old.

Results

Among 528 cases of VP shunt surgery performed in our hospital over 10 years, 146 (27.7%) were revision surgery. Infection and obstruction were the most common causes of revision. Fifty-one patients were operated on within 1 month after original VP shunt surgery. Thirty-six of 46 infection cases were operated before 6 months after the initial VP shunt. Incidence of shunt catheter fracture was higher in younger patients compared to older. Two of 8 fractured catheters in the younger group were due to calcification and degradation of shunt catheters with fibrous adhesion to surrounding tissue.

Conclusion

The complications of VP shunts were different between children and adults. The incidence of shunt catheter fracture was higher in younger patients. Degradation of shunt catheter associated with surrounding tissue calcification could be one of the reasons of the difference in facture rates.

Challenges in the Management of Hydrocephalic Children in Northern Mozambique

BACKGROUND

Hydrocephalus in sub-Saharan Africa, including Mozambique, is still a significant health care problem.

METHODS

Retrospective data from a previous study were used to determine patient provenance, referral patterns, and lost to follow-up rates.

RESULTS

Many children with hydrocephalus in this region are not taken to health care facilities for treatment. Reasons include poverty, difficult access, lack of transportation, and erroneous cultural interpretations. Resource limitations in terms of poorly equipped health care facilities and a lack of trained health professionals also contribute.

CONCLUSIONS

Efforts to improve prevention, early diagnosis, treatment, and follow-up are of utmost importance in Mozambique.

Evidence-based interventions to reduce shunt infections: a systematic review

PURPOSE

Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence.

METHODS

A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included.

RESULTS

Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates.

CONCLUSION

Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.

Cervical puncture and perimedullary cistern shunt placement for idiopathic intracranial hypertension: An alternative to lumbar cistern or cerebral ventricular catheter placement a report of two cases

Objective:

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP) in the absence of an identifiable cause, and if untreated, can result in permanent vision loss. In symptomatic IIH patients, cerebrospinal fluid (CSF) diversion can lower ICP and protect vision; however, currently used CSF diversion systems are prone to malfunction in this population.

Materials and Methods:

In two IIH patients with histories of numerous prior shunt revisions that presented with proximal ventriculoperitoneal shunt malfunction, ICP reduction was achieved by an alternative surgical cerebrospinal fluid (CSF) diversion technique: Fluoroscopically guided, percutaneous placement of a catheter in the premedullary cistern and subsequent connection to the valve and distal shunt system.

Results:

Postoperatively, both patients’ papilledema resolved, headaches improved, and the shunts were working well at 3-month follow-up. At 1-year follow-up, one patient was well without papilledema or symptom recurrence, and the second patient had the shunt system removed by an outside surgeon.

Conclusion:

This technique may hold promise as an alternative shunting strategy in IIH patients with numerous proximal shunt failures or who are poor candidates for ventricular and lumbar shunts.

Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends

OBJECT

The goal of this study is to evaluate whether an "ideal shunt" exists.

METHODS

This is a retrospective analysis based on original papers in the field of Hydrocephalus and Shunts. Patients of all age groups, who had hydrocephalus, and underwent some form of CSF diversion were included. The study has been divided into four stages: from 1900 to 1949, 1950 to 1974, 1975 to 1999, and from 2000 to 2010.

RESULTS

In stage 1 (historical era): Saphenous vein grafts, rubber conduits, and other materials were used in CSF diversions. In 1949, the first implantable shunt tube was developed by Nulsen. In stage 2 (experimental stage): the Holter valve was developed. Newer innovations were developed in relation to the ventriculo-atrial shunt, which was the preferred CSF diversion. In stage 3 (developmental stage), a large number of different design shunt systems were developed, with the aim of reducing complications. The ventriculo-peritoneal shunt had become the preferred CSF diversion. Also, the programmable valve was born. In stage 4 (era of programmable valve, there is a preference for the use of programmable shunt systems. However, shunt failure rate at 1 year being around 25 to 40%, and shunt survival at 1 and 2 years are 50-70 and 47-53% in most series.

CONCLUSION

Every shunt is an ideal shunt provided the choice of the shunt used should be made by the matching performance of the shunt system to the altered profile of CSF dynamics of a given patient. The most important factor being the opening pressure.

Study of Cerebrospinal Fluid Shunt–Associated Infections in the First Year Following Placement, by the Canadian Nosocomial Infection Surveillance Program

In a national surveillance system study, the infection rate following cerebrospinal fluid shunt surgery was 4.1% (95% confidence interval, 3.36%-4.92%). Cases of infection were more common in children than in adults (4.85% vs 3.24%; P = .04) and occurred sooner after surgery in children than in adults. A wide variation in compliance with antimicrobial prophylaxis was observed between 21 participating medical centers.

Hydrocephalus in children less than 1 year of age in northern Mozambique

Background:

In developed countries, the incidence of neonatal hydrocephalus ranges from 3 to 5 cases per 1000 live births, but little is known about the frequency of hydrocephalus in Africa. In Mozambique, there is no primary information related to this disorder, but using the above data, the expected incidence of neonatal hydrocephalus would range from 2900 to 4800 cases per year.

Methods:

This study is based on 122 children younger than 1 year with neonatal hydrocephalus, followed up between January 2010 and December 2012, their origin and treatment, and aims to evaluate difficulties with diagnosis, treatment, and follow-up in northern Mozambique.

Results:

Identified cases were mainly less than 6 months old (77%), with severe macrocephaly and the classic stigmata of this condition. A high rate of follow-up loss (44.3%) was detected, particularly among children from more distant locations. Our findings contrast with the expected 1000-1700 cases that would occur in the area during the study period, being considerably lower.

Conclusions:

Hydrocephalus is a serious problem in sub-Saharan Africa, whose effects can be minimized by a better organization of the health system in hydrocephalus prevention, referral, and follow-up. New management alternatives to provide treatment to more children with this disorder and reduction of the follow-up difficulties caused due to geographical reasons for the children undergoing treatment are essential.

Comparative effectiveness of antibiotic-impregnated shunt catheters in the treatment of adult and pediatric hydrocephalus: analysis of 12,589 consecutive cases from 287 US hospital systems

OBJECT

The real-world effectiveness of antibiotic-impregnated shunt catheters to reduce the incidence of shunt infections is still debated. The literature to date consists mostly of small, single-institution studies. The aim of this study was to assess the incidence of infection for antibiotic-impregnated catheters (AICs) versus standard shunt catheters in a large nationwide administrative database.

METHODS

The authors retrospectively reviewed hospital discharge and billing records from the Premier Perspective Database from April 2003 to July 2009 to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The primary end point was the incidence of shunt infection within 1 year of implantation. Multivariate logistical regression was performed to determine factors associated with increased incidence of infection.

RESULTS

A total of 10,819 adult (AIC, 963; standard catheter, 9856) and 1770 pediatric (AIC, 229; standard catheter, 1541) patients underwent ventricular shunt placement in 287 US hospitals. Overall, the incidence of infection was 3.5% in adults (n=380) and 6.6% in pediatric patients (n=116). AICs were associated with significant reduction in infection for both adult (2.2% vs 3.6%, p=0.02) and pediatric (2.6% vs 7.1%, p<0.01) patients. AIC use was associated with reduced infection regardless of hospital size, annual shunt volume, hospital location, or patient risk factors and remained associated with a reduced infection in multivariate analysis for both adult (p=0.02) and pediatric (p=0.02) patients.

CONCLUSIONS

The use of antibiotic-impregnated shunt catheters was associated with a reduction in shunt infections for both adult and pediatric patients. This provides further support that AICs may represent a reliable means of reducing shunt infections for both adult and pediatric patients.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 7: Antibiotic-impregnated shunt systems versus conventional shunts in children: a systematic review and meta-analysis

OBJECT

The objective of this systematic review and meta-analysis was to answer the following question: Are antibiotic-impregnated shunts (AISs) superior to standard shunts (SSs) at reducing the risk of shunt infection in pediatric patients with hydrocephalus?

METHODS

Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to AIS use in children. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was assembled summarizing the studies and the quality of their evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using the chi-square and I(2) statistics. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

RESULTS

Six studies, all Class III, met our inclusion criteria. All but one study focused on a retrospective cohort and all but one were conducted at a single institution. Four of the studies failed to demonstrate a lowered infection rate with the use of an AIS. However, when the data from individual studies were pooled together, the infection rate in the AIS group was 5.5% compared with 8.6% in the SS group. Using a random-effects model, the cumulative RR was 0.51 (95% CI 0.29-0.89, p < 0.001), indicating that a shunt infection was 1.96 times more likely in patients who received an SS.

CONCLUSIONS

We recommend AIS tubing because of the associated lower risk of shunt infection compared to the use of conventional silicone hardware (quality of evidence: Class III; strength of recommendation: Level III).

RECOMMENDATION

Antibiotic-impregnated shunt (AIS) tubing may be associated with a lower risk of shunt infection compared with conventional silicone hardware and thus is an option for children who require placement of a shunt.

STRENGTH OF RECOMMENDATION

Level III, unclear degree of clinical certainty.

Laparoscopic assisted ventriculoperitoneal shunt revisions as an option for pediatric patients with previous intraabdominal complications

Multiple shunt failure is a challenge in pediatric neurosurgery practice and one of the most feared complications of hydrocephalus.

OBJECTIVE

To demonstrate that laparoscopic procedures for distal ventriculoperitoneal shunt failure may be an effective option for patients who underwent multiple revisions due to repetitive manipulation of the peritoneal cavity, abdominal pseudocyst, peritonitis or other situations leading to a "non reliable" peritoneum.

METHOD

From March 2012 to February 2013, the authors reviewed retrospectively the charts of six patients born and followed up at our institution, which presented with previous intra-peritoneal complications and underwent ventriculoperitoneal shunt revision assisted by video laparoscopy.

RESULTS

After a mean follow-up period of nine months, all patients are well and no further shunt failure was identified so far.

CONCLUSION

Laparoscopy assisted shunt revision in children may be, in selected cases, an effective option for patients with multiple peritoneal complications due to ventriculo-peritoneal shunting.

Ventricular shunt infections: immunopathogenesis and clinical management

Ventricular shunts are the most common neurosurgical procedure performed in the United States. This hydrocephalus treatment is often complicated by infection of the device with biofilm-forming bacteria. In this review, we discuss the pathogenesis of shunt infection, as well as the implications of the biofilm formation on treatment and prevention of these infections. Many questions remain, including the contribution of glia and the impact of inflammation on developmental outcomes following infection. Immune responses within the CNS must be carefully regulated to contain infection while minimizing bystander damage; further study is needed to design optimal treatment strategies for these patients.

Paediatric ventriculoperitoneal shunt infection caused by Actinomyces neuii

We present the first reported case of ventriculoperitoneal shunt infection secondary to Actinomyces neuii in a paediatric patient. Our patient was managed with temporary shunt removal, intrathecal antibiotics and a prolonged course of intravenous and then oral antibiotics. She went on to make a complete recovery. Subsequent cerebrospinal fluid analysis at 5 months post-treatment demonstrated no evidence of residual infection.

Factors affecting quality of life in early childhood in patients with congenital hydrocephalus

BACKGROUND

Predicting the outcome of congenital hydrocephalus in early infancy and childhood is difficult. Various consequences of hydrocephalus like ophthalmic, audiometric, musculoskeletal, and the developmental abnormalities play a complex role. We analyzed the quality of life of these patients in early life.

METHODS

A prospective multispecialty assessment of the patients with congenital hydrocephalus, who had undergone ventriculoperitoneal shunt in the Pediatric Surgery unit of a tertiary care hospital, was carried out and analyzed.

RESULTS

There were 24 boys and 6 girls. Eighty-three percent were operated before the age of 3 months. Mean age at follow up was 6 years (3-9 years). Shunt complications were seen in 53% (16) of the patients, out of which 68.75% had shunt blocks. In 70% (21) of the patients, the ventricle to hemisphere ratio (VHR) was between 51 and 70%, 20% (6) had a VHR of more than 70% and only 3 patients had a VHR between 40-50%. Audiological and ophthalmic problems were seen in 20 and 66% of the children, respectively. Musculoskeletal abnormalities were present in 36% of the patients. Developmental profile showed 44% being normal, 30% retarded, and 26% were borderline cases. The schooling had started in 56.6%, out of which only one child went to a special school.

CONCLUSIONS

A multitude of problems associated with congenital hydrocephalus should be diligently diagnosed, aggressively followed and intervened with in the early years of life. Preschool management well before the peer interaction should optimize the social integration and improve the quality of life in these patients.