Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens

Cerebrospinal Fluid Shunt Infections

Cerebrospinal fluid (CSF) shunt infections are a particularly challenging clinical problem. This review article addresses epidemiology and microbiology of CSF shunt infections. Clinical care is reviewed in detail, including recent guidelines and systematic review articles. Finally, current research into prevention and treatment is highlighted, with a discussion on the mechanisms of infection.

Evaluation of ventriculoperitoneal shunt infections and risk factors in children

INTRODUCTION

To evaluate the demographic, clinical, diagnostic, and treatment data of pediatric patients with ventriculoperitoneal shunt infection and risk factors for ventriculoperitoneal shunt infection and recurrence of ventriculoperitoneal shunt infection.

METHODS

Patients aged 0-18 years who were diagnosed with ventriculoperitoneal shunt infection at Cukurova University Faculty of Medicine Hospital between 2016 and 2021 were included in the study. Demographic, clinical, laboratory, and treatment data of the patients were evaluated retrospectively. Risk factors for the development and recurrence of ventriculoperitoneal shunt infection were evaluated. Patients who underwent ventriculoperitoneal shunt but did not develop any shunt infection were selected as the control group.

RESULTS

Eighty-five patients with a diagnosis of ventriculoperitoneal shunt infection were included in the study. Fever (58.8%), anorexia (58.8%), vomiting (56.5%), and altered consciousness (54.1%) were the most common complaints at admission. The control group consisted of 48 patients. The number of shunt revisions was statistically significantly higher in the group that developed ventriculoperitoneal shunt infection compared to the control group (p < 0.001). In patients with ventriculoperitoneal shunt infection, C-reactive protein and cerebrospinal fluid protein values before shunt insertion were found to be statistically significantly higher than the control group (p < 0.001).

CONCLUSION

Ventriculoperitoneal shunt infection occurs most frequently in the first months after shunt application. Therefore, it is extremely important to prevent colonization and contamination during surgery in preventing the development of ventriculoperitoneal shunt infection. In the present study, cerebrospinal fluid protein elevation and C-reactive protein elevation before shunt application were found to be significant in terms of the development and recurrence of ventriculoperitoneal shunt infection.

A search for bacteria identified from cerebrospinal fluid shunt infections in previous surgical events

Shunt infections are a common complication when treating hydrocephalus by cerebrospinal fluid (CSF) shunt placement. The source of infecting pathogens is not well understood. One hypothesis, which we explored here, is that microorganisms persist chronically in the host long before a symptomatic infection occurs and may be detectable in surgical events preceding infection. A cohort of 13 patients was selected, for which CSF samples were available from an infection episode and from a previous surgery event, which was either an initial shunt placement or a revision. Microbiota were analyzed both directly from CSF and from isolates cultured from CSF on aerobic and anaerobic media. The detection and identification of bacteria was done with high throughput DNA sequencing methods and mass spectrometry. The presence of bacteria was confirmed in 4 infection samples, of which 2 were after initial placement and 2 after revision surgery. Taxonomic identification was consistent with clinical microbiology laboratory results. Bacteria were not detected in any of the CSF samples collected at the time of the previous surgical events. While our findings do not provide direct evidence for long-term persistence of pathogens, they suggest the need for consideration of additional source material, such as biofilm and environmental swabs, and/or the use of more sensitive and specific analytical methods.

Incidence and Management of Pseudocysts in Patients With Ventriculoperitoneal Shunts: A Study in Pakistan

BACKGROUND

Ventriculoperitoneal (VP) shunts are a common medical intervention used to treat hydrocephalus, a condition characterized by the accumulation of cerebrospinal fluid (CSF) in the brain's ventricles, leading to increased intracranial pressure. While VP shunts are effective in managing hydrocephalus, they can lead to complications such as the formation of abdominal pseudocysts, which can compromise the functionality of the shunt and pose significant health risks.

OBJECTIVE

The primary objective of this study was to determine the incidence of pseudocyst formation in patients with VP shunts in Pakistan. The secondary objective was to evaluate the outcomes of conservative versus surgical management strategies and identify risk factors associated with pseudocyst recurrence in this population.

METHODS

This prospective observational study was conducted at Jinnah Teaching Hospital, Pakistan, from January 2021 to December 2022. The study included 50 patients diagnosed with pseudocysts associated with VP shunts. Participants were managed with either conservative (observation and aspiration) or surgical interventions (shunt revision, relocation, removal, or pseudocyst excision). The primary outcome measures were the resolution rates of pseudocysts and the incidence of complications. Statistical analysis was performed using chi-square tests, t-tests, and Kaplan-Meier survival analysis, with significance set at p<0.05.

RESULTS

The study found a 3.5% incidence of pseudocysts among 1400 VP shunt patients. The median time to pseudocyst formation was 22 months (IQR 18-30). Surgical management yielded an 85% resolution rate compared to 60% for conservative management (p = 0.02). The recurrence of pseudocysts was significantly associated with advanced age (HR 1.8, 95% CI 1.1-3.2), a higher BMI (HR 2.1, 95% CI 1.3-3.7), and the presence of hydrocephalus (HR 1.6, 95% CI 1.2-2.9). Although surgical interventions had a higher complication rate (14% vs. 6% for conservative management), the difference was not statistically significant (p = 0.1).

CONCLUSION

The study highlights a 3.5% incidence of pseudocysts in VP shunt patients, with surgical management proving more effective than conservative methods despite a slightly higher, non-significant risk of complications. These findings underscore the importance of tailored patient management, particularly for those at higher risk of recurrence, and suggest the need for further research to enhance surgical techniques and outcomes, especially in resource-limited settings.

Implementation of an adapted perioperative ventriculoperitoneal shunting protocol in a tertiary center located in a low-to-middle-income country

OBJECTIVE

Preventative protocols have efficaciously reduced shunt infection in developed countries. However, the generalizability of these protocols in low-to-middle-income countries (LMICs) remains unclear. Previously, shunt insertion in the authors' center was routinely performed under institutional preventative precautions, which was updated via merging with the Hydrocephalus Clinical Research Network (HCRN) protocol. This study aimed to investigate the ventriculoperitoneal shunt (VPS) infection rates in pediatric patients following the implementation of the adapted protocol.

METHODS

The adapted protocol was implemented in all first-time VPS implantations between 2011 and 2021. The primary outcome was a 6-month shunt infection. The Pearson chi-square test was used for categorical variables and the Mann-Whitney U-test for numeric variables to evaluate the correlation with shunt infection.

RESULTS

A total of 352 first-time VPS procedures were performed adhering to the adapted protocol. The median age was 5 months, and 189 (53.7%) were male. Overall, 37 patients (10.5%) experienced shunt infection, with 30 (8.5%) occurring within the first 6 months, which was lower than 13.3% infection rate of the previous series of the same center. The infection rate was slightly higher than the 5.7% and 6.0% rates reported by HCRN studies. Patients with shunt infection were significantly younger (7.5 versus 17.5 months, P < 0.001).

CONCLUSIONS

This study validates the efficacy of an adapted perioperative protocol in mitigating shunt infection in a high-volume center in a LMIC. Adhering to a step-by-step protocol, modified to suit the healthcare resources and financial constraints of LMICs, could maintain low shunt infection rates that are roughly comparable to those of centers in high-income countries.

Comparative analysis of linezolid, vancomycin, and hyperbaric oxygen therapies in a rat model of ventriculoperitoneal shunt infection

PURPOSE

Staphylococcus epidermidis is the most common causative microorganism of ventriculoperitoneal shunt infections. This study aimed to compare linezolid and vancomycin treatments and to examine the effect of these antibiotics alone and combined with hyperbaric oxygen therapy on the amount of bacterial colonies in the experimental S. epidermidis shunt infection model.

METHODS

A shunt catheter was placed in the cisterna magna of 49 adult male Wistar albino rats. The rats were randomly divided into seven groups, as follows: sterile control, infected control, vancomycin, linezolid, hyperbaric oxygen, vancomycin + hyperbaric oxygen, linezolid + hyperbaric oxygen. In all groups except the sterile control group, 0.2 ml 107 CFU/mL S. epidermidis was inoculated to the cisterna magna. Parenteral vancomycin was administered 40 mg/kg/day to the vancomycin groups, and 50 mg/kg/day of enteral linezolid to the linezolid groups. Hyperbaric oxygen groups were given 100% oxygen at a pressure of 2.4 ATA for 50 min a day. One day after the last treatment, colony quantities in the shunt catheters and CSF were analyzed.

RESULTS

The number of CSF colonies in the linezolid group was significantly lower than in the vancomycin group (p < 0.05). The number of CSF colonies in the linezolid + HBO group was significantly lower than in the vancomycin + HBO group (p < 0.05).

CONCLUSIONS

Linezolid treatment was found to be more effective than vancomycin in ventriculoperitoneal shunt infection caused by S. epidermidis. There was no statistical difference among other treatment groups. Hyperbaric oxygen therapy is shown to contribute to the sterilization of cultures.

C1q is elevated during chronic Staphylococcus epidermidis central nervous system catheter infection

Introduction

Significant neurologic morbidity is caused by pediatric cerebrospinal fluid (CSF) shunt infections. The underlying mechanisms leading to impaired school performance and increased risk of seizures are unknown, however, a better understanding of these mechanisms may allow us to temper their consequences. Recent evidence has demonstrated important roles for complement proteins in neurodevelopment and neuroinflammation.

Methods

We examined complement activation throughout Staphylococcus epidermidis (S. epidermidis) central nervous system (CNS) catheter infection. In addition, based on accumulating evidence that C3 plays a role in synaptic pruning in other neuroinflammatory states we determined if C3 and downstream C5 led to alterations in synaptic protein levels. Using our murine model of S. epidermidis catheter infection we quantified levels of the complement components C1q, Factor B, MASP2, C3, and C5 over the course of infection along with bacterial burdens.

Results

We found that MASP2 predominated early in catheter infection, but that Factor B was elevated at intermediate time points. Unexpectedly C1q was elevated at late timepoints when bacterial burdens were low or undetectable. Based on these findings and the wealth of information regarding the emerging roles of C1q in the CNS, this suggests functions beyond pathogen elimination during S. epidermidis CNS catheter infection. To identify if C3 impacted synaptic protein levels we performed synaptosome isolation and quantified levels of VGLUT1 and PSD95 as well as pre-, post- and total synaptic puncta in cortical layer V of C3 knockout (KO) and wild type mice. We also used C5 KO and wild type mice to determine if there was any difference in pre-, post- and total synaptic puncta.

Discussion

Neither C3 nor C5 impacted synaptic protein abundance. These findings suggest that chronic elevations in C1q in the brain that persist once CNS catheter infection has resolved may be modulating disease sequalae.

Antibiofilm Strategies in Neonatal and Pediatric Infections

Biofilm-related infections pose significant challenges in neonatal and pediatric care, contributing to increased morbidity and mortality rates. These complex microbial communities, comprising bacteria and fungi, exhibit resilience against antibiotics and host immune responses. Bacterial species such as Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis commonly form biofilms on medical devices, exacerbating infection risks. Neonates and children, particularly those in intensive care units, are highly susceptible to biofilm-associated infections due to the prolonged use of invasive devices, such as central lines and endotracheal tubes. Enteral feeding tubes, crucial for neonatal nutritional support, also serve as potential sites for biofilm formation, contributing to recurrent microbial contamination. Moreover, Candida species, including Candida pelliculosa, present emerging challenges in neonatal care, with multi-drug resistant strains posing treatment complexities. Current antimicrobial therapies, while important in managing infections, often fall short in eradicating biofilms, necessitating alternative strategies. The aim of this review is to summarize current knowledge regarding antibiofilm strategies in neonates and in children. Novel approaches focusing on biofilm inhibition and dispersal show promise, including surface modifications, matrix-degrading enzymes, and quorum-sensing inhibitors. Prudent use of medical devices and exploration of innovative antibiofilm therapies are imperative in mitigating neonatal and pediatric biofilm infections.

Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Antibiotic-impregnated shunts seem to be beneficial in preventing bacterial infections and decreasing mortality by effectively inhibiting microbial growth in the shunt system and reducing the risk of shunt-associated infections. This study aimed to evaluate the efficacy of antibiotic-impregnated shunt catheters (AISC) in reducing the incidence of bacterial shunt infection in patients with hydrocephalus.

METHODS

The protocol was registered on PROSPERO. A meta-analysis was conducted by searching 3 databases (PubMed, Scopus, CENTRAL) for relevant randomized controlled trials and observational studies. We included all studies published until November 2022 in any language. The primary outcome was the rate of bacterial infections, whereas the rate of shunt failure was our secondary endpoint. Odds ratios (OR) with 95% CI were calculated using a random-effects model.

RESULTS

A total of 27 articles with 27 266 shunt operations were included in this study. The results indicated that using AISC is significantly associated with reduction in infections (OR = 0.42; 95% CI: 0.33-0.54). Regarding shunt failure, there was a tendency in favor of AISC use (OR = 0.73; 95% CI: 0.51-1.06).

CONCLUSION

Our study provided evidence that AISC is significantly associated with the reduction in the rate of bacterial ventriculoperitoneal-shunt infection. In addition, there was a tendency toward AISC to decrease shunt failure compared with the standard shunt.

Antibiotic impregnated catheters and intrathecal antibiotics for CSF shunt infection prevention in children undergoing low-risk CSF shunt surgery

BACKGROUND

Cerebrospinal fluid (CSF) shunts allow children with hydrocephalus to survive and avoid brain injury (J Neurosurg 107:345-57, 2007; Childs Nerv Syst 12:192-9, 1996). The Hydrocephalus Clinical Research Network implemented non-randomized quality improvement protocols that were shown to decrease infection rates compared to pre-operative prophylactic intravenous antibiotics alone (standard care): initially with intrathecal (IT) antibiotics between 2007-2009 (J Neurosurg Pediatr 8:22-9, 2011), followed by antibiotic impregnated catheters (AIC) in 2012-2013 (J Neurosurg Pediatr 17:391-6, 2016). No large scale studies have compared infection prevention between the techniques in children. Our objectives were to compare the risk of infection following the use of IT antibiotics, AIC, and standard care during low-risk CSF shunt surgery (i.e., initial CSF shunt placement and revisions) in children.

METHODS

A retrospective observational cohort study at 6 tertiary care children's hospitals was conducted using Pediatric Health Information System + (PHIS +) data augmented with manual chart review. The study population included children ≤ 18 years who underwent initial shunt placement between 01/2007 and 12/2012. Infection and subsequent CSF shunt surgery data were collected through 12/2015. Propensity score adjustment for regression analysis was developed based on site, procedure type, and year; surgeon was treated as a random effect.

RESULTS

A total of 1723 children underwent initial shunt placement between 2007-2012, with 1371 subsequent shunt revisions and 138 shunt infections. Propensity adjusted regression demonstrated no statistically significant difference in odds of shunt infection between IT antibiotics (OR 1.22, 95% CI 0.82-1.81, p = 0.3) and AICs (OR 0.91, 95% CI 0.56-1.49, p = 0.7) compared to standard care.

CONCLUSION

In a large, observational multicenter cohort, IT antibiotics and AICs do not confer a statistically significant risk reduction compared to standard care for pediatric patients undergoing low-risk (i.e., initial or revision) shunt surgeries.

Ventriculoperitoneal Shunt Surgery in Pediatrics: Does Preoperative Skin Antisepsis with Chlorhexidine/Alcohol Reduce Postoperative Shunt Infection Rate?

BACKGROUND

 In pediatrics, shunt infection is considered the most common complication of ventriculoperitoneal (VP) shunt insertion and the main cause of shunt failure. Careful surgical technique and hygienic skin preparations are highly important for prevention of shunt infections. Our objective was to assess the significance of using preoperative chlorhexidine/alcohol as a skin antiseptic in reducing the infection rate in pediatric VP shunts surgery.

METHODS

 We conducted a retrospective, case control study of 80 pediatric patients with active hydrocephalus. The control group (a single step of preoperative skin antisepsis using povidone-iodine and isopropyl alcohol) comprised 40 patients who underwent a shunt surgery between January 2019 and June 2020 and the study group (two steps of preoperative skin antisepsis using 2% chlorhexidine gluconate in 70% isopropyl alcohol as a first step followed by povidone-iodine as a second step) comprised 40 patients who underwent a shunt surgery between July 2020 and January 2022.

RESULTS

 Shunt infection was encountered in 11 (13.7%) patients. It was significantly higher in preterm babies (p = 0.010), patients with a previous shunt revision (p < 0.001), and those with a previous shunt infection (p < 0.001). The incidence of infection was 22.5% in the control group and 5% in study group, with a statistically significant difference (p = 0.023).

CONCLUSIONS

 Two steps of preoperative skin antisepsis, first using chlorhexidine/alcohol and then povidone-iodine scrub solution, may significantly reduce the infection rate in pediatric VP shunt surgeries.

Treatment of wound infections linked to neurosurgical implants

As neurosurgery has advanced technologically, more and more neurosurgical implants are being employed on an aging patient population with several comorbidities. As a result, there is a steady increase in the frequency of infections linked to neurosurgical implants, which causes serious morbidity and mortality as well as abnormalities of the skull and inadequate brain protection. We discuss infections linked to internal and external ventricular and lumbar cerebrospinal fluid drainages, neurostimulators, craniotomies, and cranioplasty in this article. Biofilms, which are challenging to remove, are involved in all implant-associated illnesses. It takes a small quantity of microorganisms to create a biofilm on the implant surface. Skin flora bacteria are implicated in the majority of illnesses. Microorganisms that cause disruptions in wound healing make their way to the implant either during or right after surgery. In about two thirds of patients, implant-associated infections manifest early (within the first month after surgery), whereas the remaining infections present later as a result of low-grade infections or by direct extension from adjacent infections (per continuitatem) to the implants due to soft tissue damage. Except for ventriculo-atrial cerebrospinal fluid shunts, neurosurgical implants are rarely infected by the haematogenous route. This research examines established and clinically validated principles that are applicable to a range of surgical specialties using implants to treat biofilm-associated infections in orthopaedic and trauma cases. Nevertheless, there is little evidence and no evaluation in sizable patient populations to support the success of this extrapolation to neurosurgical patients. An optimal microbiological diagnostic, which includes sonicating removed implants and extending culture incubation times, is necessary for a positive result. Additionally, a strategy combining surgical and antibiotic therapy is needed. Surgical procedures involve a suitable debridement along with implant replacement or exchange, contingent on the biofilm's age and the state of the soft tissue. A protracted biofilm-active therapy is a component of antimicrobial treatment, usually lasting 4-12 weeks. This idea is appealing because it allows implants to be changed or kept in place for a single surgical procedure in a subset of patients. This not only enhances quality of life but also lowers morbidity because each additional neurosurgical procedure increases the risk of secondary complications like intracerebral bleeding or ischemia.

Preoperative nomogram predicting ventriculoperitoneal shunt longevity after initial shunt failure

Background and objectives

Initial shunt failure following ventriculoperitoneal (VP) shunt surgery has a significant impact on the working time of the shunt. However, there are few studies regarding factors affecting VP shunt longevity. Hence, in this study, we aimed to build a nomogram to predict the longevity of the replacement VP shunt in patients with initial shunt failure.

Methods

From 2011 to 2021, 142 patients with initial VP failure who underwent VP shunt revision were enrolled and relevant clinical and demographic factors were analyzed. Univariate and multivariate Cox proportional hazard regression models were used to choose predictors, and a nomogram was constructed using nine independent prognostic variables: sex, age, hydrocephalus type, intensive care unit admission, tracheostomy, decompressive craniectomy, craniotomy, lumbar cisterna drainage, and ventricular drainage. The prediction models' discrimination, accuracy, calibration, and clinical value were evaluated using Harrell's C-index, a calibration plot, and decision curve analysis.

Results

At 1 month, 3 months, and 5 years, the nomogram's C-index was 0.680, 0.708, and 0.694, respectively. The nomogram's calibration plot provided a good fit for the overall prediction over the course of 1 year. Decision curve analysis predicted that 1-3 months after surgery will yield good net benefits between 30 and 50% probability thresholds.

Conclusion

A preoperative nomogram may be an effective tool for assessing VP shunt longevity after initial VP shunt placement.

Is It Possible to Eliminate Postoperative Shunt Infections?: Results of a Modified Hydrocephalus Clinical Research Network Protocol

BACKGROUND

 Postoperative shunt infection is a nightmare in neurosurgical practice with additional morbidity and mortality. A lot of protocols have contributed to the reduction of ventriculoperitoneal shunt (VPS) infections but not eradication. The aim of the study was to evaluate the rigid application of a modified Hydrocephalus Clinical Research Network (HCRN) protocol in the prevention of postoperative shunt infection.

METHODS

 We retrospectively evaluated children with congenital hydrocephalus who underwent VPS insertion, and in whom the protocol was applied from June 2019 to January 2020. Follow-up ranged from 11 to 24 months.

RESULTS

 Thirty-seven procedures were performed including 35 primary shunt insertions and two revision surgeries. The median age was 5 months (range, 1-30 months), and 25 patients were males. The most common cause for VPS placement was congenital hydrocephalus without identifiable cause in 28 cases (80%). The endoscope-assisted technique was used in the insertion of the proximal end in six cases (17%). The mean follow-up was 19.4 months (11-24 months). The rate of shunt infection was 0% till the last follow-up.

CONCLUSION

 The preliminary results showed an effective method for the prevention of postoperative shunt infections using the modified protocol. These initial findings need to be validated in a large prospective study before widespread application can be recommended.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population

Objective

To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies.

Method

Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records.

Results

Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected.

Conclusion

The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

Associations of Standard Care, Intrathecal Antibiotics, and Antibiotic-Impregnated Catheters With Cerebrospinal Fluid Shunt Infection Organisms and Resistance

BACKGROUND

Infection prevention techniques used during cerebrospinal fluid (CSF) shunt surgery include: (1) standard perioperative intravenous antibiotics, (2) intrathecal (IT) antibiotics, (3) antibiotic-impregnated catheter (AIC) shunt tubing, or (4) Both IT and AIC. These techniques have not been assessed against one another for their impact on the infecting organisms and patterns of antimicrobial resistance.

METHODS

We performed a retrospective longitudinal observational cohort study of children with initial CSF shunt placement between January 2007 and December 2012 at 6 US hospitals. Data were collected electronically from the Pediatric Health Information Systems+ (PHIS+) database, and augmented with standardized chart review. Only subjects with positive CSF cultures were included in this study.

RESULTS

Of 1,723 children whose initial shunt placement occurred during the study period, 196 (11%) developed infection, with 157 (80%) having positive CSF cultures. Of these 157 subjects, 69 (44%) received standard care, 28 (18%) received AIC, 55 (35%) received IT antibiotics, and 5 (3%) received Both at the preceding surgery. The most common organisms involved in monomicrobial infections were Staphylococcus aureus (38, 24%), coagulase-negative staphylococci (36, 23%), and Cutibacterium acnes (6, 4%). Compared with standard care, the other infection prevention techniques were not significantly associated with changes to infecting organisms; AIC was associated with decreased odds of methicillin resistance among coagulase-negative staphylococci.

CONCLUSIONS

Because no association was found between infection prevention technique and infecting organisms when compared to standard care, other considerations such as tolerability, availability, and cost should inform decisions about infection prevention during CSF shunt placement surgery.

Serial Neuroendoscopic Lavage for the Treatment of Elevated Cerebrospinal Fluid Protein Levels in Infants with Gram-Negative Rod Ventriculitis

INTRODUCTION

Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality.

METHODS

Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution.

RESULTS

Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0-2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/- 0.8).

CONCLUSIONS

Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection.

Cerebrospinal fluid shunt infections in children

Cerebrospinal fluid (CSF) shunts are commonly used for the long-term management of hydrocephalus in children. Shunt infection remains a common complication, occurring in about 5%-15% of CSF shunts. This narrative review summarises key evidence from recent literature on the epidemiology, pathogenesis, clinical presentation, diagnosis, management, outcomes and prevention of CSF shunt infections in children. The majority of shunt infections occur due to contamination at the time of surgery, with coagulase-negative staphylococci and Staphylococcus aureus being the most common infecting organisms. Clinical presentations of shunt infection can be varied and difficult to recognise. CSF cultures are the primary test used for diagnosis. Other CSF and blood parameters may aid in diagnosis but lack sensitivity and specificity. Core aspects of management of shunt infections include systemic antimicrobial therapy and surgical removal of the shunt. However, many specific treatment recommendations are limited by a lack of robust evidence from large studies or controlled trials. Shunt infections may result in long hospital stays, worsening hydrocephalus, neurological sequelae and other complications, as well as death. Therefore, reducing the incidence of infection and optimising management are high priorities. Antibiotic prophylaxis at the time of shunt placement, improved surgical protocols and antibiotic-impregnated shunts are key strategies to prevent shunt infections. Nevertheless, further work is needed to identify additional strategies to prevent complications and improve outcomes.

Bacterial ventriculoperitoneal shunt infections: changing trends in antimicrobial susceptibility, a 7-year retrospective study from Pakistan

BACKGROUND

Ventriculoperitoneal (VP) shunt infections in adults represent a severe complication and make treatment more challenging. Therefore, drug susceptibility patterns are crucial for therapeutic decisions and infection control in neurosurgical centers. This 7-year retrospective study aimed to identify the bacteria responsible for adult VP shunt infections and determine their drug susceptibility patterns.

METHODS

This single-center study was performed from 2015 to 2021 in Lahore, Pakistan, and included CSF cultures from VP shunt infections. Demographic data, causative organisms, and antimicrobial susceptibility testing results were collected. Multivariate analysis of variance (MANOVA) and two-sample t-tests were used to analyze and compare the antibiotic sensitivity trends over the study period.

RESULTS

14,473 isolates recovered from 13,937 CSF samples of VP shunt infections were identified and analyzed for their susceptibility patterns to antimicrobials. The proportion of Gram-negative and Gram-positive bacteria were 11,030 (76%) and 3443 (24)%, respectively. The predominant bacteria were Acinetobacter species (n = 5898, 41%), followed by Pseudomonas species (n = 2368, 16%) and coagulase-negative Staphylococcus (CoNS) (n = 1880, 13%). 100% of Staphylococcus aureus (S.aureus) and CoNS were sensitive to vancomycin and linezolid (n = 2580). However, 52% of S. aureus (719/1,343) were methicillin-resistant Staphylococcus aureus (MRSA). Acinetobacter showed maximum sensitivity to meropenem at 69% (2759/4768). Pseudomonas was 80% (1385/1863 sensitive to piperacillin-tazobactam, Escherichia coli (E. coli) showed 72% to amikacin (748/1055), while Klebsiella spp. was 57% (574/1170) sensitive to piperacillin-tazobactam. The sensitivity of piperacillin-tazobactam and meropenem for Gram-negative bacteria decreased significantly (p < 0.05) over 7 years, with 92.2% and 88.91% sensitive in 2015 and 66.7% and 62.8% sensitive in 2021, respectively.

CONCLUSION

The significant decrease in the effectiveness of carbapenem and beta-lactam/beta-lactamase inhibitor combination drugs for the common Gram-negative causative agents of VP shunt infections suggests that alternative antibiotics such as colistin, fosfomycin, ceftazidime/avibactam, ceftolozane/tazobactam, and tigecycline should be considered and in consequence included in testing panels. Additionally, it is recommended to adopt care bundles for the prevention of VP shunt infection.

Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning

INTRODUCTION

Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD).

METHODS

The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created.

RESULTS

A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04-1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33-4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76-0.99) and elective admissions (OR: 0.62, 95% CI: 0.53-0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus.

CONCLUSION

Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Small Bowel Obstruction and Enterococcus Meningitis: Rare Complications of Ventriculoperitoneal Shunt Placement

A ventriculoperitoneal (VP) shunt is a commonly used mechanical device indicated for congenital and acquired hydrocephalus in children. Although VP shunt failure is not uncommon, the symptomatology and cause of failure can vary. In this case, we describe intestinal obstruction in a three-year-old Caucasian female with a history of Pilomyxoid Astrocytoma and VP shunt placement for the management of hydrocephalus. Surgical exploration revealed ischemia of the terminal ileum secondary to VP shunt tubing-induced adhesions requiring bowel resection. A secondary VP shunt infection due to Enterococcus faecalis was also noted. Our case highlights a unique presentation of intestinal obstruction and infection that should serve to increase provider suspicion when evaluating patients presenting with abdominal distention and pain with presence of a VP shunt.

Cerebrospinal Fluid Leakage from Scrotum Secondary to Ventriculoperitoneal Shunt Migration

Ventriculoperitoneal (VP) shunts are a common neurosurgical procedure used to treat hydrocephalus. Despite their efficacy, many shunts fail and require revisions. The most common causes of shunt failure include obstruction, infection, migration, and perforation. Extraperitoneal migrations require urgent attention. We present a case of migration to the scrotum, a unique complication that may be present in young patients due to the presence of a patent processus vaginalis. Here, we discuss a case of a 16-month-old male patient with a VP shunt presenting with cerebrospinal fluid (CSF) drainage from his scrotum after an indirect hernia repair. This case represents an important reminder for physicians about the sequelae associated with VP shunt complications, particularly extraperitoneal migration, and brings awareness to the underlying factors that may increase this risk.

Ventriculopleural shunt outcomes for pediatric hydrocephalus: a single-institution experience

PURPOSE

The aim of this study is to analyze rates of ventriculopleural (VPL) shunt failure and complications among patients with pediatric hydrocephalus, and to analyze which factors may predict early (< 1 year) or late (> 1 year) VPL shunt failure in this sample.

METHODS

A retrospective chart review was conducted of all consecutive VPL shunt placements from 2000 to 2019 at our institution. Data was collected on patient characteristics, shunt history, and shunt type. Primary endpoints include rates of VPL shunt survival and rates of symptomatic pleural effusion. The Kaplan-Meier method was used to calculate shunt survival, and Fisher's exact test and t-test were used to compare differences between categorical variables and means, respectively (p < 0.05).

RESULTS

Thirty-one patients with pediatric hydrocephalus underwent VPL shunt placement (mean age 14.2 years). Of the 27 patients with long-term follow-up (mean 46 months), VPL shunt revision was required in 19, seven of which were due to pleural effusion. Overall shunt survival rates at 1, 3, 5, and 7 years were 76%, 62%, 55%, and 46%, respectively. Mean duration of shunt survival was 26.74 months. Overall pleural effusion rate was 26%. No patient-specific factors, including shunt valve type, were significantly associated with shunt survival, risk of early revision, or risk of pleural effusion.

CONCLUSIONS

Our results are comparable to those reported in the literature and represent one of the largest case series on the topic. VPL shunts are a viable second-line option when ventriculoperitoneal (VP) shunt placement is not possible or desirable, though there are high rates of shunt revision and pleural effusion.

Bacteria commonly associated with central nervous system catheter infections elicit distinct CSF proteome signatures

Background

Cerebrospinal fluid (CSF) shunt infection is a common and devastating complication of the treatment of hydrocephalus. Timely and accurate diagnosis is essential as these infections can lead to long-term neurologic consequences including seizures, decreased intelligence quotient (IQ) and impaired school performance in children. Currently the diagnosis of shunt infection relies on bacterial culture; however, culture is not always accurate since these infections are frequently caused by bacteria capable of forming biofilms, such as Staphylococcus epidermidis, Cutibacterium acnes, and Pseudomonas aeruginosa resulting in few planktonic bacteria detectable in the CSF. Therefore, there is a critical need to identify a new rapid, and accurate method for diagnosis of CSF shunt infection with broad bacterial species coverage to improve the long-term outcomes of children suffering from these infections.

Methods

To investigate potential biomarkers that would discriminate S. epidermidis, C. acnes and P. aeruginosa central nervous system (CNS) catheter infection we leveraged our previously published rat model of CNS catheter infection to perform serial CSF sampling to characterize the CSF proteome during these infections compared to sterile catheter placement.

Results

P. aeruginosa infection demonstrated a far greater number of differentially expressed proteins when compared to S. epidermidis and C. acnes infection and sterile catheters, and these changes persisted throughout the 56-day time course. S. epidermidis demonstrated an intermediate number of differentially expressed proteins, primarily at early time points that dissipated over the course of infection. C. acnes induced the least amount of change in the CSF proteome when compared to the other pathogens.

Conclusions

Despite the differences in the CSF proteome with each organism compared to sterile injury, several proteins were common across all bacterial species, especially at day 5 post-infection, which are candidate diagnostic biomarkers.

Factors affecting ventriculoperitoneal shunt revision: a post hoc analysis of the British Antibiotic and Silver Impregnated Catheter Shunt multicenter randomized controlled trial

OBJECTIVE

The British Antibiotic and Silver Impregnated Catheter Shunt (BASICS) trial established level I evidence of the superiority of antibiotic-impregnated catheters in the prevention of infection of newly implanted ventriculoperitoneal shunts (VPSs). A wealth of patient, shunt, and surgery-specific data were collected from trial participants beyond that of the prespecified trial objectives.

METHODS

This post hoc analysis of the BASICS survival data explores the impact of patient age, hydrocephalus etiology, catheter type, valve type, and previous external ventricular drain on the risk of infection or mechanical failure. Time to failure was analyzed using Fine and Gray survival regression models for competing risk.

RESULTS

Among 1594 participants, 75 patients underwent revision for infection and 323 for mechanical failure. Multivariable analysis demonstrated an increased risk of shunt infection associated with patient ages < 1 month (subdistribution hazard ratio [sHR] 4.48, 95% CI 2.06-9.72; p < 0.001) and 1 month to < 1 year (sHR 2.67, 95% CI 1.27-5.59; p = 0.009), as well as for adults with posthemorrhagic hydrocephalus (sHR 2.75, 95% CI 1.21-6.26; p = 0.016). Age ≥ 65 years was found to be independently associated with reduced infection risk (sHR 0.26, 95% CI 0.10-0.69; p = 0.007). Antibiotic-impregnated catheter use was also associated with reduced infection risk (sHR 0.43, 95% CI 0.22-0.84; p = 0.014). Independent risk factors predisposing to mechanical failure were age < 1 month (sHR 1.51, 95% CI 1.03-2.21; p = 0.032) and 1 month to < 1 year (sHR 1.31, 95% CI 0.95-1.81; p = 0.046). Age ≥ 65 years was demonstrated to be the only independent protective factor against mechanical failure risk (sHR 0.64, 95% CI 0.40-0.94; p = 0.024).

CONCLUSIONS

Age is the predominant risk for VPS revision for infection and/or mechanical failure, with neonates and infants being the most vulnerable.

Clinical Characteristics and Treatment of Early and Delayed Intra-Ccranial Infection After Ventriculoperitoneal Shunt in Adults: Retrospective Analysis of Nineteen Cases

Objectives: Intra-cranial infection is the most serious complication after ventriculoperitoneal shunt (VPS). There were differences in clinical characteristics between early (occurs within one month after VPS, the early group) and delayed (occurs 1 month or more after VPS, the delayed group) infections. The aim of this study is to clarify the differences between the two groups. Patients and Methods: All cases diagnosed as intracranial infection after VPS between September 2017 and December 2021 were collected. Clinical data were reviewed and analyzed retrospectively. Results: Nineteen cases met the inclusion criteria, including 12 cases in the early group and seven cases in the delayed group. There were no significant differences between the two groups in gender, age, and etiology of hydrocephalus. Cases in the early group usually had fever with worsening consciousness (11; 91.7%), which was caused by surgical operations (10; 83.3%) with gram-positive coccis infection (9; 75.0%), whereas those in the delayed group had abdominal pain (5; 71.4%), caused by abdominal factor (7; 100%) with gram-negative bacilli infection (6; 85.7%). There were differences in symptoms (p < 0.01), causes of infection (p < 0.001), and pathogens (p < 0.05). Shunt removal was performed for all 19 cases. After the infection was controlled, eight cases received VPS again, and no re-infection occurred after a follow-up of four to 22 months. Conclusions: It is suggested in this study that there were differences between the two groups in terms of etiology, symptoms, and pathogens. The results can provide theoretical basis for prevention, early diagnosis, and reasonable treatment of infection after VPS.

Correlation between cerebrospinal fluid abnormalities before ventriculoperitoneal shunt and postoperative intracranial infection in adult patients with hydrocephalus: A clinical study

Objective

To identify the relationship between preoperative cerebrospinal fluid (CSF) leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels and ventriculoperitoneal shunt infection.

Methods

Records of 671 consecutive adult patients who underwent ventriculoperitoneal shunt surgery for the treatment of hydrocephalus at Zhujiang Hospital affiliated with Southern Medical University from January 2011 to March 2022 were reviewed. The patients were divided into infection and non-infection groups based on the presence of postoperative infection. For all patients, we analyzed age; sex; primary disease; preoperative CSF leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels; postoperative temperature; and postoperative infection.

Results

A total of 397 patients were included, 28 (7.05%) of whom had an infection within 6 months of the operation and the remaining had no infection. There was no significant difference in age, sex, primary disease, leukocyte, chloride ion, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase and protein levels in CSF between infection group and non-infection group (p > 0.05). The postoperative infection rate of patients with CSF glucose < 2.8 mmol/L (x ² = 11.650, p = 0.001) and CSF lactic acid >2.8 mmol/L (x ² = 12.455, p < 0.001) was higher than that of patients with CSF glucose level ≥2.8 mmol/L and CSF lactic acid level in the range of (1-2.8) mmol/L, respectively, with statistical difference. Compared with the non-infection group, the level of CSF glucose (t = 4.113, p < 0.001) was significantly lower, and the level of CSF lactic acid (t = 6.651, p < 0.001) was significantly higher in the infection group. Multivariate logistic regression analysis showed that preoperative cerebrospinal fluid glucose < 2.8 mmol/L (OR = 3.911, 95% CI: 1.653~9.253, p = 0.002) and cerebrospinal fluid lactate >2.8 mmol/L (OR = 4.712, 95% CI: 1.892~11.734, p = 0.001) are risk factors for infection after ventriculoperitoneal shunt. ROC analysis revealed that the area under the curve (AUC) for CSF glucose and lactic acid level were 0.602 (95% CI: 0.492-0.713) and 0.818 (95% CI: 0.738-0.898), respectively. The infection group had higher rates of fever and body temperature on postoperative day 3-7 (p < 0.05).

Conclusions

For adult hydrocephalus patients without clinical manifestations of intracranial infection but only with simple abnormality of cerebrospinal fluid, when the content of glucose in cerebrospinal fluid is < 2.8 mmol/L, and the content of lactic acid is >2.8 mmol/L, it is recommended to perform ventriculoperitoneal shunt after further improvement of cerebrospinal fluid indicators, otherwise, hasty operation will increase the postoperative infection rate. The postoperative fever rate of ventriculoperitoneal shunt surgery is high and the body temperature drops rapidly. If there is still fever after day 3 after surgery, whether there is intracranial infection should be considered.

Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study

BACKGROUND

Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA).

METHODS

We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19-years-old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists.

RESULTS

Of the 11,878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (p<0.01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no BLA procedures with beta-lactam AMP (1.6%) .

CONCLUSIONS

Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association of non-beta-lactam AMP and SSI in children.

Mortality and complications 1 year after treatment of hydrocephalus with endoscopic third ventriculostomy and ventriculoperitoneal shunt in children at Queen Elizabeth Central Hospital, Malawi

BACKGROUND

Over the past two decades, the management of hydrocephalus has witnessed the addition of endoscopic third ventriculostomy with or without choroid plexus cauterization (ETV ± CPC) to the traditional methods including ventriculoperitoneal shunt insertion (VPSI). We conducted this study to assess mortality and complications with surgical implications associated with the two procedures in children with hydrocephalus.

METHODS

We reviewed our operating theater registry to identify children below 17 years old who underwent hydrocephalus surgery for the first time in 2016. The patients were followed for up to 1 year from the date of the initial operation. Their vital status was confirmed by follow-up visits by a community nurse. Descriptive analyses were used to describe the characteristics of the patients and evaluate the study outcomes (i.e., mortality and complications).

RESULTS

One hundred fifty-three patients were eligible for the study; 56% were males and 73.2% had primary ETV ± CPC. Complete 1-year follow-up data was available for 79 patients, and 73.4% of these had ETV ± CPC. One-year success (event-free) rates for ETV and VPSI were similar at 67.4% and 66.7%, respectively. ETVs in infants under 6 months performed poorly; failing in half the infants, who were subsequently converted to VPS. Shunt sepsis was very high, 21.4% (95% CI 10.3-36.8). The majority of surgical complications (81.8%) occurred within 3 months of surgery.

CONCLUSION

ETV ± CPC and VPSI carry a similar frequency of mortality and complications in our setting, and therefore, both should be considered as a treatment option for patients with hydrocephalus. As VP shunt is still used for managing most of the patients, there is still a need to prioritize measures to reduce shunt infections.

Symptoms of Cerebrospinal Shunt Malfunction in Young Children: A National Caregiver Survey

Objective: This study aimed to describe shunt malfunction symptoms in children ≤5 years old. Results: In a national survey of 228 caregivers, vomiting (23.1%), irritability (20.8%), and sleepiness (17.2%) were the most frequent symptoms of malfunction. These symptoms also occurred in over 1/3 of "false alarms" experienced by 75% of respondents. Compared with malfunctions, irritability (OR = 1.39, 95% CI [1.05, 1.85], p = 0.022) and fever (OR = 2.22, 95% CI [1.44, 3.44], p < 0.001) were more likely false alarms. Caregivers counseled about "most" symptoms were more confident detecting malfunctions than those informed of "some" (p = 0.036). The majority of caregivers (85%) first contacted a neurosurgeon with concerns about malfunction, followed by neurologists (22%) and family/friends (19%). Most (85%) struggled to differentiate malfunction from regular development. Conclusions: Vomiting, irritability, and sleepiness were the most common symptoms of shunt malfunction and false alarms for children ≤5 years. Most caregivers reported challenges differentiating malfunctions from their child's development.

Ventricular Peritoneal Shunting Using Modified Keen’s Point Approach: Technical Report and Cases Series

Background: Ventricular peritoneal shunting (VPS) is a frequent procedure in neurosurgery, unfortunately still burdened with a significant rate of complications. The frontal Kocher’s point is the most frequently used landmark for ventricular puncture. Keen’s point (posterior parietal approach) seems to be a valid alternative. We report a newly described access to the lateral ventricle located in posterior temporal area and the results of a large series of adult patients. Methods: Retrospective analysis of a series of 188 cases of VPS performed with this approach. Results: Mean surgical time was 51.5 +/− 13.1 min (range 25–90 min). Twenty-one patients (11.2%) were subjected to revision surgery: eight cases (4.3%) for displacement or malfunction of ventricular catheter, eight cases (4.3%) for abdominal issues, three cases (1.6%) for hardware failure, and two cases (1.1%) for infection. Optimal catheter placement was reached in 90.1%. Conclusions: The modified Keen’s point approach seems to be safe, technically feasible, and reproducible, showing some potential advantages such as short surgical time, precision in ventricular catheter placement, and short tunneling tract. The need for surgical revision is similar to that reported in the literature, while the rate of catheter malpositioning and infections seems to be low; hemorrhages around catheter and seizures were not reported.

Clinical features and risk factors of surgical site infections in HIV-negative patients with cryptococcal meningitis underwent ventriculoperitoneal shunt operations: a retrospective study

Background

To investigate the clinical features and risk factors of ventriculoperitoneal shunt (VPS) associated surgical site infections (SSIs) in HIV-negative patients with cryptococcal meningitis (CM).

Methods

We retrospectively reviewed the medical records of HIV-negative patients with CM underwent VPS operation admitted to The Third Affiliated Hospital of Sun Yat-sen University in Southwest China over the past 7 years.

Results

193 patients were included, of whom 25 (12.95%) had SSIs in 6 (median duration, 1–48 days) days after operation. Compared with patients without SSIs, patient with SSIs tended to be shorter preoperative stay. 52% patients in SSIs group and 25% patients in no-SSIs group underwent VPS operations within 3 days after admission (p = 0.017). Although body temperature and infectious indicators slightly elevated postoperative in both groups. The patients with SSIs experienced more fever; more central nervous system symptoms; higher PCT value and lower cerebrospinal fluid (CSF) glucose in contrast to the no-SSIs group. Multivariate regression analysis found a 2.653 fold increase in the risk of infection for every 1 °C increase in postoperative body temperature. Among the 25 patients, 9 patients had positive culture results, three samples reported to be oxacillin resistant coagulase-negative Staphylococci.

Conclusions

SSIs was one of the serious surgical complications after VPS operation. High body temperature, the occurrence of dizziness and headache, low postoperative hemoglobin are risk factors. Postoperative patients with high fever, high PCT and low CSF glucose should be paid more attention to.

Cerebrospinal Fluid System Infection in Children with Cancer: A Retrospective Analysis over 14 Years in a Major European Pediatric Cancer Center

Infection of a cerebrospinal fluid system is a serious medical complication. We performed a retrospective monocentric analysis on temporary and permanent cerebrospinal fluid devices in children with and without cancer, covering a period of over 14 years. Between 2004 and 2017, 275 children with a cerebrospinal fluid system were seen at our institution. Thirty-eight children suffered from 51 microbiologically proven infectious episodes of the cerebrospinal fluid system (12 children with cancer and 26 children without cancer). Independently of the cerebrospinal fluid system used, the incidence of infection did not significantly differ between children with and without cancer and was the highest in children younger than one year. Infection occurred earlier in external ventricular drain (EVD) than ventriculoperitoneal (VP) shunt, and in EVD significantly earlier in children with cancer compared with patients without cancer. The pathogens isolated were mainly Gram-positive bacteria, in particular Staphylococcus spp., which should be taken into account for empirical antimicrobial therapy.

Predictors and Outcome of Ventriculoperitoneal Shunt Infection: A Retrospective Single-Center Study

Background:Shunt infection critically affects approximately 8-10% of all inserted shunts, leading to significant morbidity and mortality. This study aimed to assess the clinical and laboratory factors associated with shunt infection and outcomes in patients treated for hydrocephalus.

Methods: A retrospective study was performed on patients who underwent ventriculoperitoneal shunt (VPS) surgery for hydrocephalus between January 2015 and June 2018. The primary outcome was the development of shunt infection following VPS surgery. Records were reviewed, and variables were analyzed, including patients' demographics, perioperative laboratory and shunt data, and outcomes. The patients had five years of follow-up from surgery, including a minimum of two years from the onset of VPS infection.

Results:A total of 132 shunts were inserted in 103 patients with a mean age of 2 years (range; 2 days to 73 years), and 53.4% were males. Twenty-two patients were suspected of having VPS infection (16.7% per procedure); only six (4.5%) had positive cerebrospinal fluid (CSF) detected organisms. Patients with preoperative hemoglobin, white blood cells, and serum glucose within normal values had a lower shunt infection rate. The pediatric population had an elevated risk of VPS infection, particularly those who underwent surgery at a younger age than 7.5 months, weighed less than 10 Kg, and were associated with myelomeningocele. in addition, a shorter surgery time of less than 82 min, single surgeon, and operating room of fewer than four attendees are associated with lower risk of VPS infection.

Conclusion:We emphasize that early identification and modifications of the risk factors can minimize the probability of developing VPS infection and improve patients outcome.

Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study

BACKGROUND

Infections complicate 5%-10% of cerebrospinal fluid (CSF) shunts. We aimed to describe the characteristics and contemporary pathogens of shunt infections in children in Canada and the United States.

METHODS

Descriptive case series at tertiary care hospitals in Canada (N = 8) and the United States (N = 3) of children up to 18 years of age with CSF shunt infections from July 1, 2013, through June 30, 2019.

RESULTS

There were 154 children (43% female, median age 2.7 years, 50% premature) with ≥1 CSF shunt infections. Median time between shunt placement and infection was 54 days (interquartile range, 24 days-2.3 years). Common pathogens were coagulase-negative staphylococci (N = 42; 28%), methicillin-susceptible Staphylococcus aureus (N = 24; 16%), methicillin-resistant S. aureus (N = 9; 5.9%), Pseudomonas aeruginosa (N = 9; 5.9%) and other Gram-negative bacilli (N = 14; 9.0%). Significant differences between pathogens were observed, including timing of infection (P = 0.023) and CSF leukocyte count (P = 0.0019); however, differences were not sufficient to reliably predict the causative organism based on the timing of infection or discriminate P. aeruginosa from other pathogens based on clinical features. Empiric antibiotic regimens, which included vancomycin (71%), cefotaxime or ceftriaxone (29%) and antipseudomonal beta-lactams (33%), were discordant with the pathogen isolated in five cases. There was variability between sites in the distribution of pathogens and choice of empiric antibiotics. Nine children died; 4 (44%) deaths were attributed to shunt infection.

CONCLUSIONS

Staphylococci remain the most common cause of CSF shunt infections, although antibiotic resistant Gram-negative bacilli occur and cannot be reliably predicted based on clinical characteristics.

A Proposed Protective Protocol Predicting Reduction of Shunt Infection

OBJECTIVE

To identify the best protective interventions against shunt infection and, hence, to find an appropriate protocol assumed to be associated with reduction of infection rates.

METHODS

A combined prospective-retrospective cohort study was conducted over a period of 5 years in 3 referral hospitals. Twelve interventions against infection practiced by blinded surgeons during ventriculoperitoneal shunt operations were surveyed and their association with the outcome of interest (i.e., shunt infection) was tested. Interventions proved to be associated with the outcome entered a multivariate logistic regression to identify the protective interventions.

RESULTS

Among a total of 392 cases, shunt infection was diagnosed in 11.5% with a median onset of 55 days. Patients' demographics, etiology of hydrocephalus, shunt-related factors, and type of preoperative antibiotics were not associated with shunt infection. Two-thirds of infected shunts revealed Staphylococcus species. Among the tested interventions, double-gloving and device and wound irrigation using vancomycin solution and the use of incision adhesive drapes proved to exhibit a significant protective effect against shunt infection, whereas operative time <40 minutes revealed a marginal protective benefit.

CONCLUSIONS

Shunt infection is a significant complication that occurs early during the first 2 months after surgery. According to the study findings, an appropriate protocol against shunt infection is assumed to be composed of double-gloving, device and wound irrigation using vancomycin solution, and the use of incision adhesive drapes. Reduced operative time had a beneficial effect against shunt infection, although it was of marginal significance in the current study.

Evaluation of Discordant Results Between FilmArray Meningitis/Encephalitis Panel and Conventional Testing in Pediatric Patients: A Multisite Retrospective Cohort Study

BACKGROUND

The FilmArray Meningitis/Encephalitis panel (MEP) has an 11% false-positive and 2.2% false-negative rate compared with conventional testing. We describe clinical characteristics, treatment decisions, and outcomes in children with discordant results between MEP and conventional testing.

METHODS

We conducted a multisite review of patients ≤ 18 years with suspected central nervous system infection and positive results by MEP or conventional testing (cerebrospinal fluid [CSF] culture, herpes simplex virus [HSV] polymerase chain reaction (PCR), and enterovirus [EV] PCR). Descriptive results are provided for patients with discordant results. Comparison between group 1 (MEP and CSF culture positive) and group 2 (MEP positive, CSF culture negative, or showing a different pathogen) was made by Mann-Whitney test for continuous and Fisher's test for categorical variables.

RESULTS

A total of 355 patients had at least one pathogen identified. More than half of patients with bacterial pathogens identified that are included in the MEP had discordant results (30/52; 58%). There were 28 samples with bacterial pathogen identified on MEP only, 1 with different bacterial pathogens on MEP and culture, and 1 with Escherichia coli identified on CSF culture only. Patients in group 1 were more likely to have CSF pleocytosis, elevated CSF protein, and decreased CSF glucose than group 2 (P < .05). Two patients were HSV positive by MEP while HSV negative by PCR. Ten patients had discordant results between MEP and EV PCR.

CONCLUSIONS

Discordant results between MEP and conventional testing are common. Treatment decisions based on a positive MEP should be made in the appropriate clinical context.

Removal of the Retained Ventricular Catheter Using the Endoscopic Monopolar Instrument

Background

Ventriculoperitoneal shunt (VPS) remains the main treatment for hydrocephalus. However, VPS revision surgery is very common. Here, we present a case in which the retained ventricular catheter was removed using the endoscopic monopolar instrument.

Methods

We report a case of a 28-year-old female who presented with VPS obstruction. She had two previous shunt revision surgeries due to shunt obstruction. Eleven years after the last one, she presented an abdominal pseudocyst that indicated a total system removal. During VPS revision surgery, a retained ventricular catheter was observed. The endoscopic monopolar instrument was introduced into the retained catheter under direct view. Coagulations in a back-and-forth movement were applied to release inner catheter adhesions. After these steps, the catheter was removed, and a new one was placed through the same route.

Results

The catheter was removed without complications, confirmed by the postoperative cranial computed tomography. The patient remained asymptomatic.

Conclusion

The described technique was effective and avoided ventricular bleeding. Further studies are necessary to validate this method.

Decadron, Diamox, and Zantac: A Novel Combination for Ventricular Shunt Failure in Pediatric Neurosurgical Patients

OBJECTIVE

Cerebral ventricular shunt failure is common and presents with symptoms that range from headaches to death. The combination of Diamox (acetazolamide), Decadron (dexamethasone), and Zantac (ranitidine) (DDZ) is used at our institution to medically stabilize pediatric patients presenting with symptomatic shunt failure before shunt revision. We describe our experience of this drug combination as a temporizing measure to decrease symptoms associated with shunt failure.

METHODS

We performed a single-center retrospective chart review of patients younger than 18 years with ventricular shunt failure who underwent a shunt revision between January 2015 to October 2017 and received DDZ before surgery. The outcome variables evaluated included pre-DDZ and post-DDZ clinical symptoms, pain scores, and vital signs.

RESULTS

There were 112 cases that received DDZ before shunt revision. The 4 most commonly reported symptoms were analyzed. Headache was observed in 42 cases pre-DDZ, and post-DDZ there was a 71% reduction in headache (P < 0.0001); emesis was reported pre-DDZ in 76 cases, and post-DDZ there was an 83% reduction (P < 0.0001); irritability was noted pre-DDZ in 30 cases, and post-DDZ there was a 77% reduction (P = 0.0003); lethargy pre-DDZ was observed in 60 cases, and post-DDZ 73% demonstrated improvement (P < 0.0001). Maximum pain scores significantly decreased post-DDZ (P < 0.0001). Heart rate, systolic, and diastolic blood pressures significantly decreased post-DDZ (P < 0.0001, P < 0.0001, P = 0.0002, respectively).

CONCLUSIONS

The combination of Decadron, Diamox, and Zantac is a novel treatment for ventricular shunt failure that may temporarily improve symptoms in patients awaiting shunt revision. Future studies could compare efficacy with other medical treatments.

Central nervous system infections associated with neurologic devices

PURPOSE OF REVIEW

To review recent data on the epidemiology, microbiology, diagnosis, and management of central nervous system (CNS) infections associated with neurologic devices.

RECENT FINDINGS

The increasing use of implanted neurologic devices has led to an increase in associated infections. Cerebrospinal fluid (CSF) inflammation may be present after a neurosurgical procedure, complicating the diagnosis of CNS infection. Newer biomarkers such as CSF lactate and procalcitonin show promise in differentiating infection from other causes of CSF inflammation. Molecular diagnostic tests including next-generation or metagenomic sequencing may be superior to culture in identifying pathogens causing healthcare-associated ventriculitis and meningitis.

SUMMARY

Neurologic device infections are serious, often life-threatening complications. Rapid recognition and initiation of antibiotics are critical in decreasing morbidity. Device removal is usually required for cure.

Pediatric Hydrocephalus and the Primary Care Provider

Hydrocephalus is a pathologic condition that results in the disruption of normal cerebrospinal fluid flow dynamics often characterized by an increase in intracranial pressure resulting in an abnormal dilation of the ventricles. The goal of this article was to provide the necessary background information to understand the pathophysiology related to hydrocephalus, recognize the presenting signs and symptoms of hydrocephalus, identify when to initiate a workup with further studies, and understand the management of pediatric patients with a new and preexisting diagnosis of hydrocephalus.

Evaluation of Risk of Gastrostomy and Ventriculoperitoneal Shunt Placement in Pediatric Patients: A Systematic Review of the Literature

A subset of patients with neurologic deficits require ventriculoperitoneal shunt (VPS) placement in addition to gastrostomy tubes (GTs). At present, the literature is inconsistent with respect to the sequence and time period between procedures that yields the lowest risk profile for GT and VPS placement. The purpose of this systematic literature review was to determine if time elapsed between VPS and GT placement was associated with infection (peritoneal and/or CSF). A systematic literature review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. PubMEd/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases were queried. Precise search terminology is available in the body of the manuscript. The initial database query yielded 88 unique articles. After abstract screening, 28 articles were identified and 6 met criteria for inclusion in the final analysis. The included studies were all retrospective analyses and reported data for 217 patients between the years of 1988 and 2016. Across all included studies, the infection rate after VPS and GT placement during the studies' surveillance period was 15.2% (n = 33/217). The cumulative rate of all reported complications in patients with both VPS and GT was 24.0% (n = 52/217). These studies suggest that placement of GT in patients with preexisting VPS does not significantly contribute to increased shunt or intraperitoneal infection. Future studies should determine the optimal time interval between VPS and GT placement and to identify the most appropriate prophylactic antibiotic regimen.

Microbial Contamination in Hospital Environment Has the Potential to Colonize Preterm Newborns' Nasal Cavities

Infants born before 28 weeks are at risk of contracting healthcare-associated infections (HAIs), which could be caused by pathogens residing on contaminated hospital surfaces. In this longitudinal study, we characterized by NGS the bacterial composition of nasal swabs of preterm newborns, at the time of birth and after admission to the Neonatal Intensive Care Unit (NICU), comparing it with that of the environmental wards at the time of delivery and during the hospitalization. We characterized the resistome on the samples too. The results showed that environmental microorganisms responsible for HAIs, in particular Staphylococcus spp., Streptococcus spp., Escherichia-Shigella spp., and K. pneumoniae, were detected in higher percentages in the noses of the babies after 13 days of hospitalization, in terms of the number of colonized patients, microorganism amount, and relative abundance. The analysis of nasal bacteria resistome evidenced the absence of resistance genes at the time of birth, some of which appeared and increased after the admission in the NICU. These data suggest that hospital surface microbiota might be transported to respiratory mucosae or other profound tissues. Our study highlights the importance of a screening that allows characterizing the microbial profile of the environment to assess the risk of colonization of the newborn.

Brucella Shunt Infection Complicated by Peritonitis: Case Report and Review of the Literature

Brucellosis is an endemic zoonotic disease in the Mediterranean basin and Middle East. The disease remains a diagnostic challenge due to an increasing trend of ambiguous and non-specific manifestations. We report a rare case of a 9-year-old boy who had a left frontotemporal arachnoid cyst with cystoperitoneal shunt who presented with fever for 2 weeks with gastrointestinal symptoms. He had no neurological manifestations. Diagnosis of Brucella shunt infection complicated with a peritoneal collection was established by isolation of the organism from cerebrospinal fluid (CSF) culture. Successful treatment was accomplished by shunt replacement and intravenous antibiotics followed by step-down oral therapy for an 18-month duration based on serological and radiological responses with no sequelae. We also reviewed the reported cases of CSF shunt infection in the literature for further guidance. Brucella shunt infection may be difficult to diagnose due to the diversity of signs and symptoms and the low yield on culture. Brucellosis should be always kept in mind in the differential diagnosis of patients living in endemic area with fever and non-specific symptoms. Diagnosis depends on a high index of suspicion. In addition to drug therapy, device replacement is advised to prevent treatment failure.

Bacteriological Profile and Antimicrobial Susceptibility Pattern of Cerebrospinal Fluid Shunt Infections in Infants and Children

BACKGROUND

Despite the advent of modern neurosurgical techniques, new antibiotics, and modern imaging techniques, infection after ventriculoperitoneal (VP) shunt insertion and/or ventriculostomy is still a serious issue.

AIM

The aim of this work was to study bacteriological profile and antimicrobial susceptibility pattern of cerebrospinal fluid shunt infections in infants and children.

MATERIALS AND METHODS

A total of 90 patients under the age of 12 years undergoing cerebrospinal fluid shunt procedures were included. The CSF shunt fluid, external ventricular drain (EVD), shunt tube tip specimens were processed as per standard microbiological techniques. The organisms isolated were subjected to antimicrobial susceptibility using the Kirby-Bauer disk diffusion method.

RESULTS

Of 20 infected patients 10 (50%) were culture positive. Most common organisms isolated were Acinetobacter baumannii 03 (30%) followed by Enterococcus faecalis 2 (20%). Two isolates of A. baumannii and one isolate of Klebsiella pneumoniae showed carbapenem resistance, which were sensitive to colistin. All Gram-positive isolates were sensitive to vancomycin and linezolid. Reinfection was found only in one (8.33%) patient. In 12 (60%) infected cases with shunt failure, revision of shunt was done. The shunt related mortality in this study was 1.11%.

CONCLUSION

Most common organisms isolated were A. baumannii followed by E. faecalis. Carbapenem resistance was noted in these isolates which were sensitive to colistin. All Gram-positive isolates were sensitive to vancomycin and linezolid.

Is cerebrospinal fluid sampling necessary at the time of first ventriculo-peritoneal shunt insertion in paediatric patients?

OBJECTIVE

We aim to evaluate whether intraoperative cerebrospinal fluid (CSF) sampling during ventriculo-peritoneal (VP) shunt insertion can predict future VP shunt infection or guide its management.

METHODS

83 paediatric patients undergoing VP shunt insertion between February 2013 and July 2019 were retrospectively identified. Patient demographics, presence of pre-operative extra ventricular drain (EVD), pre-operative CSF results, and intra-operative CSF results were identified from patient case notes and electronic clinical databases. All included patients were followed up for a minimum of 6 months for identification of shunt infection.

RESULTS

90 VP shunt insertions were performed in 83 patients. Age at time of shunt insertion ranged from 5 days to 15.8 years (mean 44.2 months). Tumours were the most common aetiology for hydrocephalus (n = 24). 67 cases (74.4%) had intra-operative CSF samples, of which 2 revealed the presence of bacteria. Only 1 patient with intra-operative CSF sampling positive for growth developed shunt infection during follow up. Two cases developed a shunt infection despite normal intra-operative CSF results. Three cases did not have intra-operative CSF sampling but developed a shunt infection during follow up. Intra-operative CSF culture achieved 33.3% sensitivity and 98.4% specificity for predicting future shunt infection (p = 0.154). The Receiver Operator Characteristic (ROC) curve of intra-operative white cell count (WCC) and shunt infection at 6 months follow up yielded an Area Under the Curve (AUC) of 50.3%.

CONCLUSION

Our results show that intraoperative CSF sampling as a method to predict future risk of shunt infection and to help inform future antibiotic prescribing is unreliable. Given an AUC of 50.3%, it is no better than chance as a diagnostic tool. Further larger studies are needed to substantiate this.

Cutibacterium acnes Central Nervous System Catheter Infection Induces Long-Term Changes in the Cerebrospinal Fluid Proteome

Cutibacterium acnes is the third most common cause of cerebrospinal fluid (CSF) shunt infection and is likely underdiagnosed due to the difficulty in culturing this pathogen. Shunt infections lead to grave neurologic morbidity for patients especially when there is a delay in diagnosis. Currently, the gold standard for identifying CSF shunt infections is microbiologic culture. However, C. acnes infection often results in falsely negative cultures; therefore, new diagnostic methods are needed. To investigate potential CSF biomarkers of C. acnes CSF shunt infection we adapted a rat model of CSF catheter infection to C. acnes. We found elevated levels of interleukin-1β (IL-1β), IL-6, chemokine ligand 2, and IL-10 in the CSF and brain tissues of animals implanted with C. acnes-infected catheters compared to sterile controls at day 1 postinfection. This coincided with modest increases in neutrophils in the CSF and, to a greater extent, in the brain tissues of animals with C. acnes infection, which closely mirrors the clinical findings in patients with C. acnes shunt infection. Mass spectrometry revealed that the CSF proteome is altered during C. acnes shunt infection and changes over the course of disease, typified at day 1 postinfection by an acute-phase and pathogen neutralization response evolving to a response consistent with wound resolution at day 28 compared to a sterile catheter placement. Collectively, these results demonstrate that it is possible to distinguish C. acnes infection from sterile postoperative inflammation and that CSF proteins could be useful in a diagnostic strategy for this pathogen that is difficult to diagnose.

Paediatric Escherichia coli bacteraemia presentations and high-risk factors in the emergency department

AIM

Escherichia coli (E coli) is a known cause of paediatric bacteraemia. The main objective was to characterise the emergency department (ED) presentations of paediatric E coli bacteraemia and secondarily to identify those related to greater severity.

METHODS

This was a sub-study of a multicentre cross-sectional prospective registry including all with E coli bacteraemia episodes between 2011 and 2016. We used multiple correspondence and cluster analysis to identify different patterns.

RESULTS

We included 291 patients and 43 met criteria for severe disease (14.3%, 95% confidence interval 11.2-19.3). We identified four types of paediatric E coli bacteraemia presentations. Two (178 patients, 61.2%) were related to well-appearing previously healthy infants with associated urinary tract infection (UTI). Well-appearing children older than 12 months old with underlying disease (n = 60, 20.6%) and non-well-appearing children of different ages (n = 53, 18.2%) corresponded to the other two types; these had associated UTI infrequently and higher severity rate (15% and 50.9%, respectively, higher when compared with the two previous types, P < .01), including the two patients who died.

CONCLUSION

There were four different types of ED paediatric E coli bacteraemia presentations with different severity. Febrile young children with associated UTI showed the best outcome.

Early Complications of Ventriculoperitoneal Shunt in Pediatric Patients With Hydrocephalus

Objective

Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for the treatment of hydrocephalus (HDC), especially in children. However, this is prone to many complications, and requires repeated surgeries, which as such increases the morbidity of the patients. It is estimated that majority of the complications occurs in the immediate post-operative period and the rate of complications decreases over the time, with no impunity to these, though. We conducted this study to know about the complications of VPS in the early post-operative period, in pediatric patients with hydrocephalus.

Materials and methods

This descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, between June 2019 and January 2020 (seven months). All patients with hydrocephalus below 12 years of age, operated for the first time were included after taking an informed consent, while those with repeated shunt procedures and elderly patients requiring shunt were excluded from the study. Patients’ details like age, gender, location, contact number, cause of hydrocephalus, date of shunt placement, type of surgery (elective or emergency) and any follow-up complications like failure, erosion, infections, ileus were noted on a predesigned proforma. After the surgery, patients were followed for a period of one month, and contacted either through the telephone or asked to visit in the outpatients on the specified days, and were evaluated for any shunt-related complications, and any of these complications suspected were further evaluated and noted. The data was analyzed using the statistical program SPSS version 19 (IBM Corp., Armonk, NY). Results are presented in the form of charts, tables and graph.

Results

During the study period, we evaluated a total of 151 patients; there were 78 (51.65%) males and 73 (48.34%) females with a male to female ratio approaching 1.1:1. The age range was from 22 days to 12 years. The mean age was 38.46 ± 7.53 months. The primary indications for the insertion of VP shunt were: congenital hydrocephalus in 70 (46.4%), post infectious hydrocephalus in 57 (37.7%), hydrocephalus due to tumor in 22 (14.6%), and post traumatic hydrocephalus in two (1.4%) patients. Among the total number of patients, 85 patients (55.6%) were done as elective cases and 66 patients (44.4%) were done as emergency cases. Complications were encountered in 30 patients (19.87%) during the follow-up of 30 days. Complications occurred between day 1 and day 20 of follow-up with a mean of 9.10 ± 1.69 2SD days.

Conclusion

VP shunt is the most widely used treatment for HDC, but is predisposed to complications and almost every fifth case of VP shunt comes across with complications. Shunt blockage, infections and abdominal wound-related complications are common earlier complications in pediatric patients with hydrocephalus.