Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey

INTRODUCTION

Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment.

OBJECTIVE

We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures.

METHODS

A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment.

RESULTS

A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 10⁹/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively.

DISCUSSION

Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.

Analysis of the Rate and Pattern of Ventriculoperitoneal Shunt Infection and Ventricular Catheter Culture Yield: A 10-Year Single-Institute Experience

AIM

We aimed to study the rate and pattern of ventriculoperitoneal shunt (VPS) infections at the Jordan University Hospital (JUH) over 10 years and investigate the yield of ventricular catheter tip culture in the evaluation of shunt infection.

PATIENTS AND METHODS

All patients operated on at our institution for ventriculoperitoneal shunt (VPS) insertion, reinsertion, and revision between 2009 and 2018 were included. Data (age, gender, pathology, and history of shunt infection) were collected from patients' files. Rates of infection and results of culture (cerebrospinal fluid and ventricular catheter tip) were obtained from laboratory records.

RESULTS

According to our hospital database, 310 patients were eligible for this study. The rate of infection was 11.1% per ventriculoperitoneal procedure, and the most common -organism was coagulase-negative Staphylococcus (CoNS) which was the cause of infection in 51.4% of the cases. Twenty-one percent of proved shunt infection cases showed a positive ventricular catheter tip culture.

CONCLUSION

The rate and pattern of shunt infections at our institution are comparable with the international figures and data. Methods of catheter tip culturing should be improved to increase the yield of this practice.

Fever in a child with cerebrospinal fluid access device or shunt: a pragmatic approach to management

Children with shunts commonly present with fever, and often the focus of infection will be unrelated to their shunt. However, as shunt infections may present with few or even no specific symptoms, evaluation of a child with a shunt presenting with fever should be careful and comprehensive to ensure shunt infections are not missed. Treatment of an infected shunt involves removal of the shunt followed by a long course of antibiotics; missing or partially treating shunt infections can result in significant morbidity and potentially even mortality. Our experience of managing children with shunts presenting with fever is that many non-specialist clinicians have little experience in this area so initial management may not always be appropriate. Those children who are most at risk of shunt infection are those who within the preceding 8 weeks have had insertion, revision or access of their shunt or chemotherapy device, or have had abdominal surgery in the presence of a ventriculoperitoneal shunt. We have chosen 8 weeks as a pragmatic time point, as in our experience the vast majority of children who have had shunt infections have presented within this period. The caveat is that this should not be used as an absolute cut-off where there is strong suspicion of shunt infection or no clear focus at a later time point.