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The role of intraventricular antibiotic therapy in the treatment of ventriculo-peritoneal shunt infection in children. Childs Nerv Syst 2021; 37:1605-1612. [PMID: 33733692 DOI: 10.1007/s00381-021-05116-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In this study, the effectiveness of intraventricular (IVT) antibiotic administration was evaluated in the treatment of ventriculo-peritoneal (VP) shunt infection by comparing patients who received only systemic antibiotic treatment with patients who received antibiotics added to systemic therapy by IVT route. METHODS From July 2009 to July 2019, 78 shunt infection episodes of 74 pediatric patients with bacterial growth in cerebrospinal fluid (CSF) culture who were treated with the diagnosis of VP shunt infection were retrospectively analyzed. The demographic data, clinical and laboratory parameters, antimicrobial management, and treatment outcomes of patients with VP shunt infections were recorded. RESULTS Thirty-eight of 78 shunt episodes received only systemic antibiotic treatment, and 40 had received IV plus IVT treatment. The mean age of the entire patient group was 16.7±21.3 months (range, 1 to 95 months). There was no significant difference between the two treatment groups in terms of mean age. The most common microorganism grown in CSF culture was coagulase-negative Staphylococcus. However, in the group that received IV plus IVT treatment, gram-negative bacteria were predominant (42.1% versus 20%), and this group had carbapenem-resistant and ESBL positive gram-negative bacteria growth. In the duration of CSF sterilization, hospital stay was statistically significantly shorter in the group receiving IV plus IVT treatment (p=0.000, p=0.000, respectively). CONCLUSION Our study shows that IVT administration of antibiotics shortens the duration of CSF sterilization, duration of antibiotic use, and the duration of hospital stay. For the treatment of VP shunt infection, the usage of IVT treatment in a particular group of a pediatric age is promising. However, further efforts should be done for supporting the current results by randomized controlled studies.
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Zhou WX, Hou WB, Zhou C, Yin YX, Lu ST, Liu G, Fang Y, Li JW, Wang Y, Liu AH, Zhang HJ. Systematic Review and Meta-Analysis of Antibiotic-Impregnated Shunt Catheters on Anti-Infective Effect of Hydrocephalus Shunt. J Korean Neurosurg Soc 2021; 64:297-308. [PMID: 33626856 PMCID: PMC7969052 DOI: 10.3340/jkns.2019.0219] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/04/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Shunt infection is a common complication while treating hydrocephalus. The antibiotic-impregnated shunt catheter (AISC) was designed to reduce shunt infection rate. A meta-analysis was conducted to study the effectiveness of AISCs in reduction of shunt infection in terms of age, follow-up time and high-risk patient population. METHODS This study reviewed literature from three databases including PubMed, EMBASE, and Cochrane Library (from 2000 to March 2019). Clinical studies from controlled trials for shunt operation were included in this analysis. A subgroup analysis was performed based on the patient's age, follow-up time and high-risk population. The fixed effect in RevMan 5.3 software (Cochrane Collaboration) was used for this meta-analysis. RESULTS This study included 19 controlled clinical trials including 10105 operations. The analysis demonstrated that AISC could reduce the infection rate in shunt surgery compared to standard shunt catheter (non-AISC) from 8.13% to 4.09% (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40-0.58; p=0.01; I2=46%). Subgroup analysis of different age groups showed that AISC had significant antimicrobial effects in all three groups (adult, infant, and adolescent). Follow-up time analysis showed that AISC was effective in preventing early shunt infections (within 6 months after implant). AISC is more effective in high-risk population (OR, 0.24; 95% CI, 0.14-0.40; p=0.60; I2=0%) than in general patient population. CONCLUSION The results of meta-analysis indicated that AISC is an effective method for reducing shunt infection. We recommend that AISC should be considered for use in infants and high-risk groups. For adult patients, the choice for AISC could be determined based on the treatment cost.
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Affiliation(s)
- Wen-Xiu Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Wen-Bo Hou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Chao Zhou
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yu-Xia Yin
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Shou-Tao Lu
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Guang Liu
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yi Fang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Jian-Wen Li
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Yan Wang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China
| | - Ai-Hua Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hai-Jun Zhang
- National United Engineering Laboratory for Biomedical Material Modification, Branden Industrial Park, Dezhou, China.,Department of Vascular & Intervention, Tenth People's Hospital of Tongji University, Shanghai, China.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Alborg, Denmark
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3
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Morosanu CO, Priscu A, Florian IS. Evaluation of the ventriculocholecystic shunt-an overview of present practice in adult and pediatric hydrocephalus. Neurosurg Rev 2021; 44:2533-2543. [PMID: 33481136 PMCID: PMC8490219 DOI: 10.1007/s10143-021-01472-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/14/2023]
Abstract
In the context of hydrocephalus, there are a multitude of therapeutic options that can be explored in order to improve patient outcomes. Although the peritoneum is the current elected clinical solution, various receptacles have been utilized when experiencing contraindications. Along with the ventriculoatrial or ventriculopleural, the ventriculocholecystic shunt was also described as an alternative. In order to make a decision on a place for drainage, the surgeon must be knowledgeable on details from modern literature. The main target of this review was to summarize the currently available information on this topic and assess the status of the gallbladder as a viable option for cerebrospinal fluid diversion.
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Affiliation(s)
| | - Adelina Priscu
- Department of Internal Medicine, Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
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4
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Robinson JL, Freire D, Bialy L. Treatment strategies for cerebrospinal shunt infections: a systematic review of observational studies. BMJ Open 2020; 10:e038978. [PMID: 33303443 PMCID: PMC7733168 DOI: 10.1136/bmjopen-2020-038978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE A systematic review was conducted of studies comparing time to cerebrospinal fluid (CSF) sterilisation or rate of recurrence with different treatment strategies for CSF shunt infections. METHODS A librarian-directed search was conducted of Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid Medline Daily and Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL Plus with Full Text via EBSCOhost, Scopus Advanced Search, and Web of Science Core Collection from 1990 to May 2019. Studies of any design that compared outcomes in groups of any age with different management strategies were included. Studies that compared complete versus incomplete shunt removal were excluded. Quality assessment was performed with the Newcastle-Ottawa Scale. RESULTS The search identified 2208 records, of which 8 met the inclusion criteria. All were cohort studies of moderate quality. Four studies compared the duration of antibiotics; none demonstrates that a longer course prevented recurrences. Two studies analysed addition of rifampin, with one showing a decrease in recurrences while the other had a small sample size. No studies analysed the addition of intraventricular antibiotics, but one showed equally good results with once versus twice daily administration. One study reported no difference in recurrences with placement of antibiotic-impregnated catheters. Recurrence rates did not differ with shunt replacement minimum of 7 days vs less than 7 days after CSF became sterile. There were no recurrences in either group when shunt replacement was performed after sterile CSF cultures were obtained at 24 vs 48 hours after antibiotics were discontinued. A new shunt entry site did not decrease recurrences. DISCUSSION The main limitations are the lack of high-quality studies, the small sample sizes and the heterogeneity which precluded meta-analysis. Addition of rifampin for staphylococcal infections may decrease relapse but requires further study.
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Affiliation(s)
- Joan L Robinson
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Dolores Freire
- Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Liza Bialy
- Pediatrics and Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Translation Platform, University of Alberta, Edmonton, Alberta, Canada
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5
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Gaderer C, Schaumann A, Schulz M, Thomale UW. Neuroendoscopic lavage for the treatment of CSF infection with hydrocephalus in children. Childs Nerv Syst 2018; 34:1893-1903. [PMID: 29995267 DOI: 10.1007/s00381-018-3894-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The treatment of infectious CSF condition with ventriculitis and hydrocephalus in children is an interdisciplinary challenge. Conventional surgical treatment includes external ventricular drain (EVD) and systemic antibiotic therapy. However, infectious contamination of large ventricles combined with CSF protein overload often requires long treatment regimens. We retrospectively investigated neuroendoscopic lavage as a new option for clearance of CSF in children with hydrocephalus and active CSF infection. PATIENTS AND METHODS A database review identified 50 consecutive patients treated for CSF infection with hydrocephalus at our institution. Twenty-seven patients (control group, CG) were treated conventionally between 2004 and 2010, while 23 patients (neuroendoscopic group, NEG) underwent neuroendoscopic lavage for removal of intraventricular debris between 2010 and 2015. Clinical data, microbiology, laboratory measures, shunt dependency, and shunt revision rate were evaluated retrospectively. RESULTS The patient groups did not differ regarding basic clinical characteristics. Patients in NEG received neuroendoscopic lavage at mean of 1.6 ± 1times (1-4). No immediate postoperative complications were observed in NEG patients. Shunt rate in NEG patients was 91% as compared 100% in CG patients (p = 0.109). Within 24 months after shunt implantation, incidence of shunt revision was higher in CG (23/27) compared to NEG (5/23; p < 0.001). Reinfection was observed more often in CG (n = 17) compared to one patient in NEG (p < 0.001). CONCLUSIONS We experienced that neuroendoscopic lavage is a safe and effective treatment for hydrocephalus in children with infectious conditions. Neuroendoscopic lavage resulted in a decreased number of overall shunt revisions in shunt-depended patients as well as a lower number of recurrent infections.
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Affiliation(s)
- C Gaderer
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - A Schaumann
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - M Schulz
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - U W Thomale
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Tandean S, Hendriansyah L, Djokomuljanto S, Saputra NA, Juliansen A, Valentina S, Mulry MA, July J. Neuroendoscopic aspiration and lavage of intraventricular empyema following shunt infection in infants. Pan Afr Med J 2018; 31:15. [PMID: 30918543 PMCID: PMC6430859 DOI: 10.11604/pamj.2018.31.15.16631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/10/2018] [Indexed: 11/14/2022] Open
Abstract
Bacterial ventriculitis is one of the most common and serious complications of shunt placement. Shunt infection has varied management and is difficult to treat neurosurgically. We report a case of intraventricular empyema due to shunt infection. Standard management was failed for this case and reaccumulation of pus in the both ventricles. Neuroendoscopic surgery with intraventricular lavage and aspiration using cannula nasogastric tube (NGT) through a single burr hole, has successfully decreased the accumulation of intraventricular empyema. After lavage and aspiration, antibiotic can be distributed effectively to the affected area. Follow up imaging and cerebrospinal fluid (CSF) culture shown a good result and shorter length of stay in the hospital. Neuroendoscopy appears effective and safe for the management of bacterial ventriculitis due to shunt infection in infant. The strategy described in this report might be useful to treat intraventricular empyema.
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Affiliation(s)
- Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University, Neuroscience Centre Siloam Hospital Lippo Village, Tanggerang, Indonesia.,Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Lutfi Hendriansyah
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University, Neuroscience Centre Siloam Hospital Lippo Village, Tanggerang, Indonesia
| | | | - Nico Adi Saputra
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University, Neuroscience Centre Siloam Hospital Lippo Village, Tanggerang, Indonesia
| | - Andry Juliansen
- Department of Pediatric, Siloam Lippo Karawaci Hospital, Tanggerang, Indonesia
| | - Silvia Valentina
- Faculty of Medicine, Pelita Harapan University, Tanggerang, Indonesia
| | - Monica Ann Mulry
- Undergraduate School of Medicine National University of Ireland, Galway, Ireland
| | - Julius July
- Department of Neurosurgery, Faculty of Medicine, Pelita Harapan University, Neuroscience Centre Siloam Hospital Lippo Village, Tanggerang, Indonesia
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7
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McMullan BJ, Andresen D, Blyth CC, Avent ML, Bowen AC, Britton PN, Clark JE, Cooper CM, Curtis N, Goeman E, Hazelton B, Haeusler GM, Khatami A, Newcombe JP, Osowicki J, Palasanthiran P, Starr M, Lai T, Nourse C, Francis JR, Isaacs D, Bryant PA. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. THE LANCET. INFECTIOUS DISEASES 2016; 16:e139-52. [PMID: 27321363 DOI: 10.1016/s1473-3099(16)30024-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 03/04/2016] [Accepted: 03/29/2016] [Indexed: 12/22/2022]
Abstract
Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.
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Affiliation(s)
- Brendan J McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, NSW, Australia
| | - David Andresen
- Department of Infectious Diseases, Immunology, and HIV Medicine, St Vincent's Hospital, Darlinghurst, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Christopher C Blyth
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, WA, Australia; PathWest Laboratory Medicine, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Minyon L Avent
- The University of Queensland, UQ Centre for Clinical Research and School of Public Health, Herston, QLD, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, WA, Australia; Menzies School of Health Research, Darwin, NT, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Philip N Britton
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Celia M Cooper
- Department of Microbiology and Infectious Diseases, SA Pathology, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Emma Goeman
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Briony Hazelton
- Sydney Medical School, University of Sydney, NSW, Australia; Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, WA, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Control, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Infection and Immunity, Monash Children's Hospital, Clayton, VIC, Australia
| | - Ameneh Khatami
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - James P Newcombe
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Pamela Palasanthiran
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, NSW, Australia
| | - Mike Starr
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Tony Lai
- Department of Pharmacy, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Clare Nourse
- Infection Management and Prevention Service, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Joshua R Francis
- Department of Paediatrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - David Isaacs
- Department of Infectious Diseases & Microbiology, Children's Hospital at Westmead, Westmead, NSW, Australia; Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Penelope A Bryant
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia; Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.
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8
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James HE, Postlethwait RA, Sandler ED. Solid noninfectious growing masses over cerebrospinal fluid shunts: report of 3 cases. J Neurosurg Pediatr 2015; 15:406-9. [PMID: 25634820 DOI: 10.3171/2014.10.peds14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe 3 children who presented with progressively enlarging skin-covered solid masses over the shunt catheter in the neck/clavicular region. The authors reviewed the clinical, laboratory, pathological, radiographic, and follow-up data for all 3 patients and reviewed the literature on the subject. The patients had no clinical evidence of an infectious process. Surgical exploration revealed that masses were surrounding and encasing the shunt tubing to which they were strongly attached. Pathological studies of the tissues demonstrated varying degrees of exuberant chronically inflamed granulation tissues, interstitial fibrosis, and dystrophic calcification. One patient had associated thinning of the skin overlying the mass and subsequently developed ulceration. No infectious organisms were observed. The cerebrospinal fluid aspirates from the shunts did not yield any organisms. There has been no recurrence of the masses. The presence of a growing mass over the shunt tube in the neck or the chest region without clinical evidence of infection does not indicate that the mass should be treated with antibiotics and complete shunt removal. Rather, the mass can be cured by extirpation and with "bypass" new shunt tubing locally.
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Affiliation(s)
- Hector E James
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Florida College of Medicine Jacksonville/Wolfson Children's Hospital; and
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Tamber MS, Klimo P, Mazzola CA, Flannery AM. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection. J Neurosurg Pediatr 2014; 14 Suppl 1:60-71. [PMID: 25988784 DOI: 10.3171/2014.7.peds14328] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus? METHODS The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I-III). RESULTS A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria). CONCLUSIONS Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. RECOMMENDATION Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection. STRENGTH OF RECOMMENDATION Level II, moderate degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. STRENGTH OF RECOMMENDATION Level III, unclear degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. STRENGTH OF RECOMMENDATION Level III, unclear degree of clinical certainty.
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Affiliation(s)
- Mandeep S Tamber
- Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis,3Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Catherine A Mazzola
- Division of Pediatric Neurological Surgery, Goryeb Children's Hospital, Morristown, New Jersey
| | - Ann Marie Flannery
- Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri
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10
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Adams DJ, Rajnik M. Microbiology and Treatment of Cerebrospinal Fluid Shunt Infections in Children. Curr Infect Dis Rep 2014; 16:427. [DOI: 10.1007/s11908-014-0427-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Drew RJ, Cole TS, Lee MK, Paulus S, Mallucci CL, Riordan A. Antimicrobial treatment options for neurosurgical ventricular shunt infections in children from 1993 to 2012: a systematic review. Childs Nerv Syst 2014; 30:841-50. [PMID: 24322604 DOI: 10.1007/s00381-013-2333-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this systematic review was to review studies that existed from 1993 to 2012 regarding antimicrobial treatment options of paediatric neurosurgical shunt. METHODS Studies were identified from MEDLINE, Scopus and Cochrane databases using a search strategy that was registered on the PROSPERO database. Studies were included if they had two or more patients, aged less than 18 years, and also specified the organism and antimicrobial treatment that was used. RESULTS The search yielded 2,985 articles, and 76 articles were suitable for full review. In the final qualitative analysis, only eight studies were included, involving 86 participants. The most common antimicrobial regimens for Gram-positive infections was intravenous and intrathecal vancomycin (n = 7), followed by intravenous vancomycin monotherapy. CONCLUSION This systematic review has shown that there are no prospective randomised studies of antimicrobial treatment options for paediatric neurosurgical patients in the last 20 years, and larger prospective studies are urgently required for this serious infection. There is some limited case series showing the benefits of certain antimicrobials such as vancomycin and ceftriaxone, but a larger case series or randomised controlled trial is required, particularly to establish the benefit, if any, of additional intraventricular antimicrobials.
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Affiliation(s)
- Richard J Drew
- Department of Clinical Microbiology, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK,
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12
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Ventriculoperitoneal Shunt Surgery and the Risk of Shunt Infection in Patients with Hydrocephalus: Long-Term Single Institution Experience. World Neurosurg 2012; 78:155-63. [DOI: 10.1016/j.wneu.2011.10.034] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 07/18/2011] [Accepted: 10/21/2011] [Indexed: 11/23/2022]
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13
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Klimo P, Thompson CJ, Ragel BT, Boop FA. Antibiotic-impregnated shunt systems versus standard shunt systems: a meta- and cost-savings analysis. J Neurosurg Pediatr 2011; 8:600-12. [PMID: 22132919 DOI: 10.3171/2011.8.peds11346] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Infection is a serious and costly complication of CSF shunt implantation. Antibiotic-impregnated shunts (AISs) were introduced almost 10 years ago, but reports on their ability to decrease the infection rate have been mixed. The authors conducted a meta-analysis assessing the extent to which AISs reduce the rate of shunt infection compared with standard shunts (SSs). They also examined cost savings to determine the degree to which AISs could decrease infection-related hospital expenses. METHODS After conducting a comprehensive search of multiple electronic databases to identify studies that evaluated shunt type and used shunt-related infection as the primary outcome, 2 reviewers independently evaluated study quality based on preestablished criteria and extracted data. A random effects meta-analysis of eligible studies was then performed. For studies that demonstrated a positive effect with the AIS, a cost-savings analysis was conducted by calculating the number of implanted shunts needed to prevent a shunt infection, assuming an additional cost of $400 per AIS system and $50,000 to treat a shunt infection. RESULTS Thirteen prospective or retrospective controlled cohort studies provided Level III evidence, and 1 prospective randomized study provided Level II evidence. "Shunt infection" was generally uniformly defined among the studies, but the availability and detail of baseline demographic data for the control (SS) and treatment (AIS) groups within each study were variable. There were 390 infections (7.0%) in 5582 procedures in the control group and 120 infections (3.5%) in 3467 operations in the treatment group, yielding a pooled absolute risk reduction (ARR) and relative risk reduction (RRR) of 3.5% and 50%, respectively. The meta-analysis revealed the AIS to be statistically protective in all studies (risk ratio = 0.46, 95% CI 0.33-0.63) and in single-institution studies (risk ratio = 0.38, 95% CI 0.25-0.58). There was some evidence of heterogeneity when studies were analyzed together (p = 0.093), but this heterogeneity was reduced when the studies were analyzed separately as single institution versus multiinstitutional (p > 0.10 for both groups). Seven studies showed the AIS to be statistically protective against infection with an ARR and RRR ranging from 1.7% to 14.2% and 34% to 84%, respectively. The number of shunt operations requiring an AIS to prevent 1 shunt infection ranged from 7 to 59. Assuming 200 shunt cases per year, the annual savings for converting from SSs to AISs ranged from $90,000 to over $1.3 million. CONCLUSIONS While the authors recognized the inherent limitations in the quality and quantity of data available in the literature, this meta-analysis revealed a significant protective benefit with AIS systems, which translated into substantial hospital savings despite the added cost of an AIS. Using previously developed guidelines on treatment, the authors strongly encourage the use of AISs in all patients with hydrocephalus who require a shunt, particularly those at greatest risk for infection.
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Affiliation(s)
- Paul Klimo
- Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee 38120, USA.
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Wong GKC, Wong SM, Poon WS. Ventriculoperitoneal shunt infection: intravenous antibiotics, shunt removal and more aggressive treatment? ANZ J Surg 2011; 81:307. [DOI: 10.1111/j.1445-2197.2011.05690.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Weiner GM, Bui CJ, Steele RW. An infant with an MRSA ventriculo-gallbladder shunt infection. Clin Pediatr (Phila) 2011; 50:269-71. [PMID: 21307082 DOI: 10.1177/0009922810390803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Bakhsh A. CSF shunt complications in infants--an experience from Pakistan. Pediatr Neurosurg 2011; 47:93-8. [PMID: 21822002 DOI: 10.1159/000329628] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 05/23/2011] [Indexed: 11/19/2022]
Abstract
AIMS AND OBJECTIVE The main aim of the study was to find out the postoperative complications and long-term outcome of cerebrospinal fluid-shunted patients in an infantile age group with a poor socioeconomic background. MATERIAL AND METHODS A prospective study of 100 cases of infantile hydrocephalus was conducted at Pakistan Institute of Medical Sciences, Islamabad, Pakistan. All selected patients suffering from congenital and post-meningitic hydrocephalus were operated on for ventriculoperitoneal shunt. However, cases of hydrocephalus secondary to myelomeningocele were not included. Patients were followed postoperatively for 2 years. Prior consent for surgery was taken from all parents and the study was approved by the hospital's academic and ethical council. RESULTS The majority of patients were brought quite late to the medical facilities because of social taboos and socioeconomic conditions. Early signs and symptoms of hydrocephalus were either ignored or misunderstood. Shunt infection and shunt failure rates remained at 14 and 10%, respectively. 50% of shunt blocks occurred in the first postoperative year and another 50% within 2 years. The highest percentage (40-45%) of death occurred in patients suffering from congenital hydrocephalus, in the first postoperative year. CONCLUSIONS This study concluded that the outcome and prognosis of shunted infantile hydrocephalus in developing countries is suboptimal due to different socioeconomic conditions. However, under such circumstances, careful selection of patients, timely intervention and adherence to meticulous aseptic surgical techniques can alter the prognosis of cerebrospinal fluid-shunted infants.
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Affiliation(s)
- Ahmed Bakhsh
- Saad Specialist Hospital, Al-Khobar, Kingdom of Saudi Arabia.
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