[Prevention of infections in ventriculoperitoneal shunts in children]

Risk factors for neurosurgical site infections: an 18-month prospective survey

OBJECT

The purpose of this study was to determine the incidence rate and risk factors of surgical site infections (SSIs) in neurosurgery for any type of surgery and any American Society of Anesthesiologists class.

METHODS

The authors undertook an exhaustive 18-month prospective survey including patients who underwent neurosurgery. In particular, a 30-day follow-up was completed in patients whose surgery did not involve placement of a prosthesis or implant, and 1-year follow-up was completed for patients who underwent surgery to place a prosthesis or implant. The Centers for Disease Control definition of SSI was used. Univariate and multivariate analyses were conducted; all dependent variables found in univariate analysis were entered in the multiple regression model. A stepwise multiple logistic regression method was used.

RESULTS

Of the 844 patients studied, 35 SSIs were diagnosed, yielding an incidence rate of 4.1% (95% confidence interval 3.6-4.5). Independent predictive risk factors for infection were cerebrospinal fluid leakage, external shunt, Altemeier class, and further neurosurgery. A lack of antibiotic prophylaxis was not found to be a risk factor.

CONCLUSIONS

Infection risk factors occur mainly during the postoperative period.

[Trans-umbilical access and ventriculoperitoneal shunt in adults: preliminary results]

In spite of the development of endoscopic surgery in hydrocephalus, ventriculoperitoneal shunt remains indicated in many cases particularly for non obstructive hydrocephalus. The peritoneal cavity is always an excellent receptacle for the LCS at the price of an unaesthetic abdominal scar, which may pose a problem, especially for the young adult. The trans-umbilical approach allows us to avoid the unsightly scar. Thus, between May 2004 and September 2006, a ventriculoperitoneal shunt was fashioned in 14 patients using a trans-umbilical access. Average age was 52 years and average post-intervention follow-up was 17 months. No patient developed infection, in particular in the umbilical area. One patient had to undergo a second operation for ventricular repositioning using the same peritoneal drain that could be repositioned via the trans-umbilical access with no particular problem. In one particular case, a full change of the shunt was necessary because of a sore on the shunt chamber, the material was reinstalled via the conventional umbilical access without any particular difficulty. This is the first preliminary study which confirms the feasibility of the trans-umbilical method for adults with no increase in the infectious risk, and with a very satisfactory aesthetic result in children.

[Infections of cerebrospinal fluid shunts in the child: prevention and treatment]

Cerebrospinal fluid (CSF) shunting has developed into the mean method of treatment in children with hydrocephalus. Until the last decade, shunt infection was the most important cause of morbidity with a mean rate of 10%. Most of shunt infection (> 90%) are diagnosed within six months after surgery supporting a basic premise of direct contamination at the time of surgery. However, after applying stricter operative and perioperative protocols, some authors reported a dramatically decrease in the incidence of infectious complications. The overall annual risk of shunt infection in a paediatric neurosurgical unit is currently 1%. Risk factors are analysed with emphasis on the choice of preventive treatment. An outline of the protocol for shunt implantation is presented. There is no clearly defined role for prophylactic antibiotic medications in the prevention of shunt infection. The small sample sizes of prospective controlled clinical trials precluded sufficient statistical power. The conclusions of the meta-analyses are not sufficiently robust to resolve the controversy and it is not possible to make recommendations either for or against the use of prophylaxis in shunt surgery. The management of shunt infection is examined with emphasis on antibiotic therapy.