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Lozano M, Wang AS, Siddiqi I, Dy O, Ko K, Sweiss R, Miulli DE. Extraventricular Drain Care Bundle Decreases Cerebrospinal Fluid Infection Rates Associated With Extraventricular Drain-Related Procedures and Systemic Infection. Cureus 2024; 16:e52440. [PMID: 38371086 PMCID: PMC10871024 DOI: 10.7759/cureus.52440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/16/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Infection associated with extraventricular drain (EVD)-related procedures is well known. OBJECTIVE To investigate the impact of our institution's EVD care bundle on the infection rates associated with EVD-related procedures. METHODS A retrospective study was conducted from June 2022 to June 2023 to compare the infection rate six months before and six months after the implantation of the EVD care bundle. RESULTS A total of 58 patients were included in the study (n=33 patients in 2022 and n=25 patients in 2023). The infection rate was 21.2% (7/33) prior to the implementation of the EVD care bundle and 0.0% (0/25) afterward. The seven patients with cerebrospinal fluid (CSF) infection did not have a higher total number of EVD-related procedures compared to the other 26 patients without CSF infection (8.0 vs. 9.4, p=0.7364); however, the mean number of EVD replacements was higher in patients with CSF infection (1.4 vs. 3.4, p=0.0028). The total number of EVD-related procedures was not different between 2022 and 2023 (8.3 vs. 5.2, respectively, p=0.1892); however, the mean number of EVD replacements was lower in 2023 (1.8 vs. 1.0, p=0.0257). In 2022, 22/33 patients had systemic infection, among which 7/22 also had CSF infection. In 2023, 13/25 patients had a systemic infection, among which 0/13 had CSF infection. CONCLUSIONS The EVD care bundle consisting of standardizations, checklists, and monitoring reduces the CSF infection rates associated with EVD-related procedures and systemic infection.
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Affiliation(s)
- Marissa Lozano
- Neuro Intensive Care Unit, Arrowhead Regional Medical Center, Colton, USA
| | - Alice S Wang
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Imran Siddiqi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Opal Dy
- Neuro Intensive Care Unit, Arrowhead Regional Medical Center, Colton, USA
| | - Katherine Ko
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neuro Intensive Care Unit, Arrowhead Regional Medical Center, Colton, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neuro Intensive Care Unit, Arrowhead Regional Medical Center, Colton, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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Rojas-Lora M, Corral L, Zabaleta-Carvajal I, López-Ojeda P, Fuentes-Mila V, Romera-Peregrina I, Lerma-Briansò C, Plata-Menchaca E, Pavón A, Sabater J, Cabellos C. External ventriculostomy-associated infection reduction after updating a care bundle. Ann Clin Microbiol Antimicrob 2023; 22:59. [PMID: 37454149 DOI: 10.1186/s12941-023-00612-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients' characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017. RESULTS From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements. CONCLUSIONS A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.
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Affiliation(s)
- Mariel Rojas-Lora
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Luisa Corral
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | - Ivan Zabaleta-Carvajal
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Pau López-Ojeda
- Neurosurgery Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Verónica Fuentes-Mila
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Iluminada Romera-Peregrina
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Cristina Lerma-Briansò
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Erika Plata-Menchaca
- Vall d'Hebron Research Institute, Passeig de La Vall d'Hebron, 129, 08035, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Alba Pavón
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Sabater
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Carmen Cabellos
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
- Departament de Ciències Clíniques, Universitat de Barcelona, Av. Mare de Déu de Bellvitge, 3, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
- Centro de Investigación Biomédica de Enfermedades Infecciosas (CIBERINFEC, ISCIII), Madrid, Spain
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Muacevic A, Adler JR. The Impact of Nursing Education on Emergency Bedside External Ventricular Drain Insertion for Patients With Acute Hydrocephalus. Cureus 2023; 15:e34262. [PMID: 36843801 PMCID: PMC9957584 DOI: 10.7759/cureus.34262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 02/28/2023] Open
Abstract
Objectives Acute hydrocephalus is a neurosurgical emergency that requires immediate intervention. With emergency external ventricular drain (EVD) insertion and management, such rapid intervention can be a safe bedside procedure. Nurses play an integral role in patient management. Thus, this study aims to assess the knowledge, attitudes, and practices of nurses from different departments regarding bedside EVD insertion in patients with acute hydrocephalus. Methods EVD and intracranial pressure (ICP) monitoring competency checklists were developed, and a quasi-experimental, single-group, pre/post-test study was conducted at a university hospital in Jeddah, Saudi Arabia, in January 2018 during an educational program. The neurosurgery team determined program efficacy using pre/post-questionnaires. All attendees who agreed to fill in the pre- and post-survey and whose data were complete were included in the study. Results Of the 140 nurses who participated in the study, the data of 101 were analyzed. Knowledge level improved significantly between the pre- and post-test; for example, when asked about administering antibiotics before EVD insertion, the pre-test correct response rate of 65% increased to 94% in the post-test (p<0.001), and 98% considered the session informative. However, the attitude toward bedside EVD insertion did not change after the teaching sessions. Conclusion This study emphasizes the importance of ongoing nursing education, hands-on training, and strict adherence to an EVD insertion checklist to achieve successful bedside management of patients with acute hydrocephalus.
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Risk factors and outcomes associated with external ventricular drain infections. Infect Control Hosp Epidemiol 2022; 43:1859-1866. [PMID: 35471129 PMCID: PMC9753061 DOI: 10.1017/ice.2022.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Insertion of an external ventricular drain (EVD) is a common neurosurgical procedure which may lead to serious complications including infection. Some risk factors associated with EVD infection are well established. Others remain less certain, including specific indications for placement, prior neurosurgery, and prior EVD placement. OBJECTIVE To identify risk factors for EVD infections. METHODS We reviewed all EVD insertions at our institution from March 2015 through May 2019 following implementation of a standardized infection control protocol for EVD insertion and maintenance. Cox regression was used to identify risk factors for EVD infections. RESULTS 479 EVDs placed in 409 patients met inclusion criteria, and 9 culture-positive infections were observed during the study period. The risk of infection within 30 days of EVD placement was 2.2% (2.3 infections/1,000 EVD days). Coagulase-negative staphylococci were identified in 6 of the 9 EVD infections). EVD infection led to prolonged length of stay post-EVD-placement (23 days vs 16 days; P = .045). Cox regression demonstrated increased infection risk in patients with prior brain surgery associated with cerebrospinal fluid (CSF) diversion (HR, 8.08; 95% CI, 1.7-39.4; P = .010), CSF leak around the catheter (HR, 21.0; 95% CI, 7.0-145.1; P = .0007), and insertion site dehiscence (HR, 7.53; 95% CI, 1.04-37.1; P = .0407). Duration of EVD use >7 days was not associated with infection risk (HR, 0.62; 95% CI, 0.07-5.45; P = .669). CONCLUSION Risk factors associated with EVD infection include prior brain surgery, CSF leak, and insertion site dehiscence. We found no significant association between infection risk and duration of EVD placement.
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Reiter LA, Taylor OL, Jatta M, Plaster SE, Cannon JD, McDaniel BL, Anglin M, Lockhart ER, Harvey EM. Reducing External Ventricular Drain (EVD) Associated Ventriculitis: An improvement project in a Level 1 Trauma Center. Am J Infect Control 2022; 51:644-651. [PMID: 36116678 DOI: 10.1016/j.ajic.2022.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND External ventricular drain (EVD)-associated infections have a negative impact on healthcare cost and patient outcomes. Practice variation in EVD management may place patients at increased risk for EVD-associated infection. This project aimed to evaluate the impact of implementing an interprofessional evidence-based EVD bundle of care on reduction of EVD-related ventriculitis rates. METHODS An interprofessional team developed an evidence based EVD care bundle and order set to eliminate practice inconsistencies. Standardization of EVD equipment and optimization of the electronic health record occurred. Education and competency validation were completed with neurosurgical providers and nurses. Interprofessional rounds occur weekly for observation, recognition, and in-the-moment education. RESULTS A pre/post intervention design was used to show that the rate of EVD-associated ventriculitis decreased from 8.8 per reported EVD days in 2019 to 0 per reported EVD days in 2021 after implementation of the EVD care bundle. CONCLUSION Through an interprofessional team approach, reduction in EVD-associated infection rates is feasible with implementation of an evidence based EVD care bundle.
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Affiliation(s)
- Laura A Reiter
- Department of Human Resources: Education and Organizational Development, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014.
| | - Olga L Taylor
- Department of Inpatient Surgical Services, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Maimuna Jatta
- Department of Infection Prevention and Control, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Shannen E Plaster
- Department of Inpatient Surgical Services, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Joseph D Cannon
- Department of Quality and Patient Safety, Carilion Roanoke Memorial Hospital, 2017 S Jefferson Street, Roanoke VA, 24014
| | - Bradford L McDaniel
- Department of Pharmacy Services, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Mia Anglin
- Department of Neurosurgery, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Ellen Rachel Lockhart
- Department of Health Analytics and Research, Carilion Clinic, 1906 Belleview Ave SE, Roanoke, VA, 24014
| | - Ellen M Harvey
- Department of Inpatient Surgical Services, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave SE, Roanoke, VA, 24014
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Akeret K, Buzzi RM, Saxenhofer M, Bieri K, Chiavi D, Thomson BR, Grüttner-Durmaz M, Schwendinger N, Humar R, Regli L, van Doormaal TPC, Held U, Keller E, Hugelshofer M, Schaer DJ. The HeMoVal study protocol: a prospective international multicenter cohort study to validate cerebrospinal fluid hemoglobin as a monitoring biomarker for aneurysmal subarachnoid hemorrhage related secondary brain injury. BMC Neurol 2022; 22:267. [PMID: 35850705 PMCID: PMC9290286 DOI: 10.1186/s12883-022-02789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Preclinical studies provided a strong rationale for a pathophysiological link between cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) and secondary brain injury after subarachnoid hemorrhage (SAH-SBI). In a single-center prospective observational clinical study, external ventricular drain (EVD) based CSF-Hb proved to be a promising biomarker to monitor for SAH-SBI. The primary objective of the HeMoVal study is to prospectively validate the association between EVD based CSF-Hb and SAH-SBI during the first 14 days post-SAH. Secondary objectives include the assessment of the discrimination ability of EVD based CSF-Hb for SAH-SBI and the definition of a clinically relevant range of EVD based CSF-Hb toxicity. In addition, lumbar drain (LD) based CSF-Hb will be assessed for its association with and discrimination ability for SAH-SBI. Methods HeMoVal is a prospective international multicenter observational cohort study. Adult patients admitted with aneurysmal subarachnoid hemorrhage (aSAH) are eligible. While all patients with aSAH are included, we target a sample size of 250 patients with EVD within the first 14 day after aSAH. Epidemiologic and disease-specific baseline measures are assessed at the time of study inclusion. In patients with EVD or LD, each day during the first 14 days post-SAH, 2 ml of CSF will be sampled in the morning, followed by assessment of the patients for SAH-SBI, co-interventions, and complications in the afternoon. After 3 months, a clinical follow-up will be performed. For statistical analysis, the cohort will be stratified into an EVD, LD and full cohort. The primary analysis will quantify the strength of association between EVD based CSF-Hb and SAH-SBI in the EVD cohort based on a generalized additive model. Secondary analyses include the strength of association between LD based CSF-Hb and SAH-SBI in the LD cohort based on a generalized additive model, as well as the discrimination ability of CSF-Hb for SAH-SBI based on receiver operating characteristic (ROC) analyses. Discussion We hypothesize that this study will validate the value of CSF-Hb as a biomarker to monitor for SAH-SBI. In addition, the results of this study will provide the potential base to define an intervention threshold for future studies targeting CSF-Hb toxicity after aSAH. Study registration ClinicalTrials.gov Identifier NCT04998370. Date of registration: August 10, 2021.
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Affiliation(s)
- Kevin Akeret
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Raphael M Buzzi
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | | | | | - Deborah Chiavi
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Bart R Thomson
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Manuela Grüttner-Durmaz
- Clinical Trials Center - Research Ward (CTC-RW), University Hospital Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Rok Humar
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Tristan P C van Doormaal
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland.,Department of Neurology and Neurosurgery, University Medical Center, Utrecht, The Netherlands
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurointensive Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Michael Hugelshofer
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland.
| | - Dominik J Schaer
- Division of Internal Medicine, Universitätsspital and University of Zurich, Zurich, Switzerland
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Kerry G, Holtmannspoetter M, Kubitz JC, Steiner HH. Factors which influence the complications of external ventricular cerebrospinal fluid drainage. Acta Neurochir (Wien) 2022; 164:483-493. [PMID: 34626273 DOI: 10.1007/s00701-021-05007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND External ventricular drainage (EVD) is one of the most common neurosurgical procedures in emergencies. This study aims to find out which factors influence the occurrence of EVD-related complications in a comparative investigation of metal needles and polyurethane catheters. This is the first clinical study comparing these two systems. METHODS Adult patients undergoing pre-coronal EVD placement via freehand burr hole trepanation were included in this prospective study. The exclusion criteria were the open EVD insertion and/or a pre-existing infectious disease of the central nervous system. RESULTS Two hundred consecutive patients were enrolled. Of these, 100 patients were treated by using metal EVD (group 1) and 100 patients with polyurethane catheters (group 2). The overall complication rate was 26% (misplacement 13.5%, hemorrhage 12.5%, infection 2.5%, and dislocation 1%) without statistically significant differences between both groups. Generalized brain edema and midline shift had a significant influence on misplacements (generalized brain edema: p = 0.0002, Cramer-V: 0.307, OR = 7.364, 95% CI: 2.691-20.148; all patients: p = 0.001, Cramer-V: 0.48, OR = 43.5, 95% CI: 4.327-437.295; group 1: p = 0.047, Cramer-V: 0.216, OR = 3.75, 95% CI: 1.064-13.221; group 2: midline shift: p = 0.038, Cramer-V: 0.195, OR = 3.626, 95% CI: 1.389-9.464) all patients: p = 0.053, Cramer-V: 0.231, OR = 5.533, 95% CI 1.131-27.081; group 1: p = 0.138, Cramer-V: 0.168, OR = 2.769, 95% CI: 0.813-9.429 group 2. Hemorrhages were associated with the use of oral anticoagulants or antiplatelet therapy (p = 0.002; Cramer-V: 0.220, OR = 3.798, 95% CI: 1.572-9.175) with a statistically similar influence in both groups. CONCLUSION Generalized brain edema has a significant influence on misplacements in both groups. Midline shift lost its significance when considering only the patients in group 2. Patients under oral anticoagulation and antiplatelet therapy have increased odds of EVD-associated hemorrhage. Metal needles and polyurethane catheters are equivalent in terms of patient safety when there are no midline shift and generalized brain edema.
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Affiliation(s)
- Ghassan Kerry
- Department of Neurosurgery, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany.
- Medical Faculty, University of Heidelberg, Heidelberg, Germany.
| | - Markus Holtmannspoetter
- Department of Neuroradiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Jens Christian Kubitz
- Department of Anesthesiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
- Medical Faculty, University of Heidelberg, Heidelberg, Germany
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Karvouniaris M, Brotis A, Tsiakos K, Palli E, Koulenti D. Current Perspectives on the Diagnosis and Management of Healthcare-Associated Ventriculitis and Meningitis. Infect Drug Resist 2022; 15:697-721. [PMID: 35250284 PMCID: PMC8896765 DOI: 10.2147/idr.s326456] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/05/2022] [Indexed: 12/31/2022] Open
Abstract
Ventriculitis or post-neurosurgical meningitis or healthcare-associated ventriculitis and meningitis (VM) is a severe infection that complicates central nervous system operations or is related to the use of neurosurgical devices or drainage catheters. It can further deteriorate patients who have already presented significant neurologic injury and is associated with high morbidity, mortality, and poor functional outcome. VM can be difficult to distinguish from aseptic meningitis, inflammation that follows hemorrhagic strokes and neurosurgical operations. The associated microorganisms can be either skin flora or nosocomial pathogens, most commonly, Gram-negative bacteria. Classical microbiology can fail to isolate the culprit pathogen. Novel cerebrospinal fluid (CSF) biomarkers and molecular microbiology can fill the diagnostic gap and expedite pathogen identification and treatment. The pathogens may demonstrate significant resistant patterns and their antibiotic treatment can be difficult, as many important drug classes, including the beta-lactams and the glycopeptides, hardly penetrate to the CSF, and do not achieve therapeutic levels at the site of the infection. Treatment modifications, such as higher daily dose and prolonged or continuous administration, might increase antibiotic levels in the site of infection and facilitate pathogens clearance. However, in the case of therapeutic failure or infection due to difficult-to-treat bacteria, the direct antibiotic instillation into the CSF, in addition to the intravenous antibiotic delivery, may help in the resolution of infection. However, intraventricular antibiotic therapy may result in aseptic meningitis and seizures, concerning the administration of aminoglycosides, polymyxins, and vancomycin. Meanwhile, bacteria form biofilms on the catheter or the device that should routinely be removed. Novel neurosurgical treatment modalities comprise endoscopic evacuation of debris and irrigation of the ventricles. VM prevention includes perioperative antibiotics, antimicrobial impregnated catheters, and the implementation of standardized protocols, regarding catheter insertion and manipulation.
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Affiliation(s)
- Marios Karvouniaris
- Intensive Care Unit, AHEPA University Hospital, Thessaloniki, Greece
- Correspondence: Marios Karvouniaris, ACHEPA University Hospital, S.Kiriakidi 1, Thessaloniki, 54636, Greece, Tel +302313303645, Fax +302313303096, Email
| | - Alexandros Brotis
- Neurosurgery Department, University Hospital of Larissa, Larissa, Greece
| | | | - Eleni Palli
- Intensive Care Unit, University Hospital of Larissa, Larissa, Greece
| | - Despoina Koulenti
- Second Critical Care Department, Attikon University Hospital, Athens, Greece
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Thamjamrassri T, Yuwapattanawong K, Chanthima P, Vavilala MS, Lele AV. A Narrative Review of the Published Literature, Hospital Practices, and Policies Related to External Ventricular Drains in the United States: The External Ventricular Drain Publications, Practices, and Policies (EVDPoP) Study. J Neurosurg Anesthesiol 2022; 34:21-28. [PMID: 32467476 PMCID: PMC9014964 DOI: 10.1097/ana.0000000000000694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
Abstract
External ventricular drain (EVD) placement and management pose risks to neurocritically ill patients. Yet, little is known about EVD management or hospital EVD management practices and policies in US hospitals. A narrative review was conducted to describe EVD-related publications reported in PubMed and Embase between 1953 and 2019, and a survey was used to examine US hospital EVD practices and policies, including adherence to EVD guideline recommendations. Overall, 912 relevant articles were published between 1953 and 2019 (average 21; range, 0 to 102 articles, per year), primarily related to indications for EVD placement (n=275, 30.2%), EVD-associated complications (n=206, 22.6%), and EVD care (n=200, 21.9%). The number of EVD publications increased over time (R2=0.7), and most publications addressed EVD-associated infection (n=296, 73.4%) and EVD insertion (n=195, 45.2%). Survey responses were received from 30 hospitals (37.5% response rate), and reported use of antimicrobial-impregnated catheters in 80% of hospitals, preinsertion antibiotic administration in 70%, collection of cerebrospinal fluid samples for suspicion of ventriculitis in 73.3%, tracking of EVD-associated infection in 86.7%, routine EVD clamping during transport in 66.7%, and monitoring of intracranial pressure during transport in 33.3%. Adherence to hospital policies was high for recommendations related to flushing an EVD and changing cerebrospinal fluid drainage systems (100% [range, 0% to 100%] each), but low for intrahospital transportation (16.7% [0% to 83.3%]), EVD removal (0% [0% to 66.7%]), patient and family education (0% [0% to 100%]), and administration of intraventricular medication (0% [0% to 100%]). In summary, the published literature related to EVD insertion and maintenance, and reported EVD hospital practices and policies, primarily focus on reducing EVD-associated infections. Still, overall adherence of hospital EVD policies to guideline recommendations is modest. To promote a culture of EVD safety, clinicians should focus on reducing all EVD-associated adverse events.
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Affiliation(s)
| | | | | | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Abhijit V Lele
- Harborview Injury Prevention and Research Center, Harborview Medical Center
- Neurocritical Care Service
- Department of Anesthesiology and Pain Medicine, Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
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Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163:1135-1142. [PMID: 33427989 DOI: 10.1007/s00701-020-04698-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency placement of an external ventricular drain (EVD) is one of the most frequently performed neurosurgical procedures. EVD-related infection continues to be a major challenge causing significant morbidity and costs. Bundle approaches have been shown to reduce infection rates; however, they are still not widely used, and observation periods often were rather short. METHODS The present study evaluated the effect of a multi-item bundle approach for EVD placement and care on the occurrence of EVD-related infection. A before/after approach was used to compare groups of consecutive patients over 5-year epochs to control for bias and secondary confounding variables. RESULTS The number of patients in the group before implementation of the bundle approach was 141 and 208 thereafter. There were no statistical differences in demographic and other variables. While 41/141 patients (29.1%) had an EVD-related infection before, this was the case in only 10/208 patients (4.8%) thereafter (p < 0.0001). The EVD-related infection rate was reduced from 13.7/1000 catheter days to 3.2/1000, and the 50% probability of an EVD-related infection in correlation to the mean duration of EVD placement was significantly lower (p < 0.0001). Routine EVD replacement was not helpful to reduce EVD-related infection. EVD-related infection rates remained low also over the next 8 years after the study was finished. CONCLUSIONS The introduction of a multi-item bundle approach for EVD insertion and care resulted in a marked reduction of EVD-related infection. Long observation periods over 5 years and beyond confirm that short-term changes are sustained with continued use of such protocols.
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Suresh V, Ushakumari PR, Pillai CM, Kutty RK, Prabhakar RB, Peethambaran A. Implementation and adherence to a speciality-specific checklist for neurosurgery and its influence on patient safety. Indian J Anaesth 2021; 65:108-114. [PMID: 33776084 PMCID: PMC7983834 DOI: 10.4103/ija.ija_419_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/29/2020] [Accepted: 07/23/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Neurosurgery involves a high level of expertise coupled with enduring and long duration of working hours. There is a paucity of published literature about the experience with a speciality-specific checklist in neurosurgery. We conducted a cross-sectional observational study to identify the adherence to various elements of the Modified World Health Organization Surgical Safety Checklist (WHO SSC) for neurosurgery by the operating room (OR) team. Methods We implemented an intra-operative Modified WHO SSC consisting of 40 tools for neurosurgery, in 200 consecutive elective cases. Trained anaesthesiologists assumed the role of checklist co-ordinator. The checklist divided the surgery into 5 phases, each corresponding to a specific time-period. The adherence rates to various tools were evaluated and areas where the checklist prompted a corrective measure were analysed. Results A total of 131 cases undergoing craniotomy and 69 cases undergoing spine surgery were studied. With the 40-point modified SSC applied in 200 cases, we analysed a total of 8000 observations. The modified checklist prompted the OR team to adhere to speciality-specific safety practices about application of compression stockings (9.5%); airway precautions in unstable cervical spine (2.5%); precautions for treatment of raised intracranial pressure (10.5%); and intraoperative neuro-monitoring (5%). Conclusion The implementation of Modified WHO SSC for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the OR time. The anaesthesiologist as SSC coordinator can effectively implement an intraoperative checklist ensuring excellent participation of operating room team members.
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Affiliation(s)
- Varun Suresh
- Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - P R Ushakumari
- Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - C Madhusoodanan Pillai
- Department of Anaesthesiology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Raja Krishnan Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
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Fang W, Wei A, Zhu Y, You W, Wang H, Wen L, Yang X. Contribution of Patient Care Technicians to the Prevention of External Ventricular Drain Infection: A Retrospective Study. J Neurosci Nurs 2021; 53:44-48. [PMID: 33177368 DOI: 10.1097/jnn.0000000000000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: External ventricular drains (EVDs) are commonly used in neurosurgery. Preventing EVD-related infections is important, and nursing plays a significant role in infection control. However, because of the limited number of neurosurgical nurses and heavy workload in developing countries, well-trained patient care technicians (PCTs) might be able to assist nurses under this circumstance. METHODS: This study retrospectively screened patients who underwent EVD procedures in our medical center from January 2012 to June 2018. Clinical characteristics including EVD-related infection rates of patients with or without PCTs were compared. RESULTS: We analyzed 234 patients in total. There were 26 EVD infection cases, and the overall infection rate was 11.1%. There were 122 patients who were given additional care by PCTs. They were elder (58.1 ± 13.1 vs 49.9 ± 17.0 years old, P < .001) and had lower level preoperational Glasgow Coma Scale (7.04 ± 3.66 vs 13.5 ± 2.53, P < .001) and higher intubation rate (28.7% vs 3.6%, P < .001) than those without PCTs. They also had a longer drainage duration (10.3 ± 4.97 vs 8.01 ± 4.35, P < .001) as well as more cerebrospinal fluid sampling times (2.45 ± 2.00 vs 1.75 ± 1.83, P = .006) and were kept at artificial airway status for a longer duration (10.1 ± 18.7 vs 1.93 ± 7.86, P < .001). External ventricular drain-related infection rates were similar between 2 groups (11.5% vs 10.7%, P = .853). CONCLUSION: Patient care technicians with proper training are beneficial to the prevention of EVD-related infection as a measure of improving staffing adequacy.
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Affiliation(s)
- Rimal H Dossani
- From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport
| | - Devi P Patra
- From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport
| | - Danielle L Terrell
- From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport
| | - Brian Willis
- From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport
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Tamburri LM, Hollender KD, Orzano D. Protecting Patient Safety and Preventing Modifiable Complications After Acute Ischemic Stroke. Crit Care Nurse 2020; 40:56-65. [PMID: 32006035 DOI: 10.4037/ccn2020859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC Protecting patient safety and preventing modifiable complications after acute ischemic stroke. CLINICAL RELEVANCE Stroke is a leading cause of death and disability in adults. Stroke survivors often experience a variety of deficits related to mobility, nutrition, immunity, mood, and cognition. These post-stroke complications and residual effects can adversely affect safety, placing the patient at risk for further injury. In order to develop a plan of care that protects patient safety, critical care and progressive care nurses must understand the unique needs of this patient population. PURPOSE To describe selected ischemic stroke-related physiological changes, how these changes contribute to safety risks, and methods of enhancing patient safety. CONTENT COVERED Stroke physiology and stroke-specific interventions that can enable nurses to reduce the risk of falls, dysphagia, malnutrition, dehydration, altered glucose metabolism, device-related infections, aspiration pneumonia, delirium, and depression.
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Affiliation(s)
- Linda M Tamburri
- Linda M. Tamburri is a clinical nurse specialist, Magnet/Quality Department, critical care float pool, and specialty care transport unit, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Kimberly D Hollender
- Kimberly D. Hollender and Devon Orzano are acute care nurse practitioners, stroke neurology and neurocritical care, Robert Wood Johnson University Hospital
| | - Devon Orzano
- Kimberly D. Hollender and Devon Orzano are acute care nurse practitioners, stroke neurology and neurocritical care, Robert Wood Johnson University Hospital
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15
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Sheppard JP, Ong V, Lagman C, Udawatta M, Duong C, Nguyen T, Prashant GN, Plurad DS, Kim DY, Yang I. Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases. Neurosurgery 2020; 86:19-29. [PMID: 30476297 DOI: 10.1093/neuros/nyy522] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 10/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. OBJECTIVE To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. METHODS We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. RESULTS Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. CONCLUSION Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.
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Affiliation(s)
- John P Sheppard
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Vera Ong
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Methma Udawatta
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Courtney Duong
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - David S Plurad
- Department of Trauma Surgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Dennis Y Kim
- Department of Trauma Surgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Isaac Yang
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Head and Neck Surgery, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Radiation Oncology, Ronald Regan UCLA Medical Center, Los Angeles, California.,Jonsson Comprehensive Cancer Center, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Neurosurgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
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16
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Whyte C, Alhasani H, Caplan R, Tully AP. Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance. Clin Neurol Neurosurg 2020; 190:105641. [DOI: 10.1016/j.clineuro.2019.105641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 10/25/2022]
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17
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Talibi SS, Silva AHD, Afshari FT, Hodson J, Roberts SAG, Oppenheim B, Flint G, Chelvarajah R. The implementation of an external ventricular drain care bundle to reduce infection rates. Br J Neurosurg 2020; 34:181-186. [DOI: 10.1080/02688697.2020.1725436] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sayed Samed Talibi
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Adikarige HD Silva
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Fardad T. Afshari
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Stuart AG Roberts
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Beryl Oppenheim
- Department of Microbiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Graham Flint
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Ramesh Chelvarajah
- Department of Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Dasgupta D, D'Antona L, Aimone Cat D, Toma AK, Curtis C, Watkins LD, Thorne L. Simulation workshops as an adjunct to perioperative care bundles in the management of external ventricular drains: improving surgical technique and reducing infection. J Neurosurg 2019; 131:1620-1624. [PMID: 30497209 DOI: 10.3171/2018.5.jns172881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Temporary CSF diversion through an external ventricular drain (EVD) comes with the risk of EVD-related infections (ERIs). The incidence of ERIs varies from 0.8% to 22%. ERIs increase mortality, morbidity, length of stay, and costs; require prolonged courses of antibiotics; and increase the need for subsequent permanent CSF diversion. The authors report the results of a quality improvement project designed to improve infection rates and EVD placement using simulation training in addition to a standardized perioperative care bundle. This project resulted not only in a decrease in ERIs, but also a significant improvement in surgical outcomes. METHODS A best-practice standardized perioperative approach and care bundle was approved by consensus among the senior neurosurgeons at the authors' institution, and a standardized operative note was designed to encourage adherence to policy and improve documentation. This approach was adapted from the bundle previously described by Kubilay et al. Simulation workshops were introduced to teach safe sampling technique, administration of intrathecal drugs, and a standardized operative technique using the Rowena head surgical model. Effects of the interventions on placement, infection rates, and displacement were measured at two distinct time points over a 2-year period. RESULTS Baseline audits demonstrated satisfactory EVD placement in 74%, an infection rate of 8.5%, and displacement occurring in 20%. In the 2 years following the interventions, satisfactory placement improved to 96%, infection rate fell to 4.8%, and inadvertent displacement occurred in only 1.7%. CONCLUSIONS Simulation training and standardizing the perioperative care of patients requiring EVDs dramatically improved placement accuracy, reduced infection rates, and reduced EVD displacement rate.
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Affiliation(s)
- Debayan Dasgupta
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
| | - Linda D'Antona
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
| | - Daniel Aimone Cat
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
| | - Ahmed K Toma
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
| | - Carmel Curtis
- 2Department of Clinical Microbiology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Laurence D Watkins
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
| | - Lewis Thorne
- 1Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square; and
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Abstract
Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.
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Affiliation(s)
- Aaron Sylvan Lord
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, NY, USA.
| | - Joseph Nicholson
- NYU Health Sciences Library, New York University School of Medicine, New York, NY, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University School of Medicine, New York, NY, USA
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20
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Intracranial Monitoring in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Champey J, Mourey C, Francony G, Pavese P, Gay E, Gergele L, Manet R, Velly L, Bruder N, Payen JF. Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study. J Neurosurg 2019; 130:2034-2039. [PMID: 29932377 DOI: 10.3171/2018.1.jns172486] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units. METHODS Between 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever. RESULTS A total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively. CONCLUSIONS These findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.
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Affiliation(s)
| | | | | | | | | | | | | | - Lionel Velly
- 6Pôle Anesthésie Réanimation, CHU La Timone, Marseille
| | | | - Jean-François Payen
- 1Pôle Anesthésie Réanimation
- 7Université Grenoble Alpes, Grenoble Institute of Neurosciences, Grenoble; and
- 8INSERM, U1216, Grenoble, France
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Hussein K, Rabino G, Feder O, Eghbaryeh H, Zayyad H, Sviri G, Benenson R, Paul M. Risk factors for meningitis in neurosurgical patients with cerebrospinal fluid drains: prospective observational cohort study. Acta Neurochir (Wien) 2019; 161:517-524. [PMID: 30666453 DOI: 10.1007/s00701-019-03801-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage or intracranial pressure (ICP) monitoring devices are life-saving devices. We examined the risk factors for infections related to them and assessed the effect of an infection control (IC) intervention. METHODS A prospective observational study was conducted in the Neurosurgical Department of our hospital between 2014 and 2017. We included all consecutive patients undergoing CSF catheter insertions, including external ventricular drainage (EVD), lumbar drainage (LD), and ICP catheters. An IC intervention was implemented between March and August 2016. We examined risk factors for meningitis or ventriculitis, defined according to Healthcare-associated infections surveillance definitions, on univariate and multivariate analysis. RESULTS A total of 232 patients with 437 drains (212 EVDs, 92 LDs, and 133 ICPs) were included. On univariate and multivariate analysis, the infection incidence was 13.7 per 1000 drain days (17.3/1000 before IC intervention, 7.9/1000 during, and 9.2/1000 after the intervention). Most episodes were caused by Gram-negative bacteria, and the most common pathogen was Acinetobacter baumanii. Risk factors for infection per patient included diabetes mellitus (p = 0.017), CSF leak (p = 0.032), drain opening (p = 0.027), and the duration of the drain in days (p = 0.035). Risk factors per catheter included drain opening (p < 0.001), drain days (p = 0.001), and the IC intervention period compared to before the intervention period (p = 0.037). When restricting the analysis to EVDs, drain days (p = 0.001) was the only significant risk factor. CONCLUSIONS Strict adherence to IC, shortening drain duration, and avoiding unnecessary opening and manipulation of the drains are crucial to preventing neurosurgical drain infections.
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Affiliation(s)
- Khetam Hussein
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel.
| | - Galit Rabino
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Omri Feder
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Haneen Eghbaryeh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Gil Sviri
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Rima Benenson
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Nuvials Casals X. Skin antisepsis in invasive procedures. Med Intensiva 2018; 43 Suppl 1:35-38. [PMID: 30454966 DOI: 10.1016/j.medin.2018.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/02/2018] [Accepted: 09/20/2018] [Indexed: 11/28/2022]
Abstract
Skin antisepsis in invasive procedures aims to reduce the bacterial load at the site of incision or puncture. Alcohol solutions seem to be more effective in preventing surgical site infection. From the safety point of view there is the potential risk of ignition when using alcohol solutions. Given the potential neurotoxicity of alcohol and chlorhexidine gluconate, contact of antiseptic solutions with the central nervous system should be avoided. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.
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Affiliation(s)
- X Nuvials Casals
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, España.
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Berger-Estilita J, Passer M, Giles M, Wiegand J, Merz TM. Modalities and accuracy of diagnosis of external ventricular drainage-related infections: a prospective multicentre observational cohort study. Acta Neurochir (Wien) 2018; 160:2039-2047. [PMID: 30066191 DOI: 10.1007/s00701-018-3643-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Device infection is a major complication of placement external ventricular drains (EVD). Diagnostic features are often masked by underlying disease or cerebrospinal fluid (CSF) contamination by blood. We aim to assess which diagnostic modalities are applied for EVD-related infection (ERI) diagnosis and evaluate their accuracy. METHODS This observational prospective study included 187 adult patients with an EVD. Modalities of clinical diagnosis of ERI diagnosed by treating physicians on clinical grounds and blood and CSF analysis (clinically diagnosed ERI (CD-ERI)) were assessed prospectively. Additionally, the diagnostic accuracy of clinical and laboratory parameters for the diagnosis of culture proven ERI (CP-ERI) was evaluated, using data of the study patients and including a retrospective cohort of 39 patients with CP-ERI. RESULTS Thirty-one CD-ERIs were diagnosed in the prospective cohort. Most physicians used CSF analysis to establish the diagnosis. ROC analysis revealed an AUC of 0.575 (p = 0.0047) for the number of positive SIRS criteria and AUC of 0.5420 (p = 0.11) for the number of pathological neurological signs for diagnosis of CP-ERI. Diagnostic accuracy of laboratory values was AUC 0.596 (p = 0.0006) for serum white blood cell count (WBCC), AUC 0.550 (p = 0.2489) for serum C-reactive protein, AUC 0.644 (p < 0.0001) for CSF WBCC and AUC 0.690 for CSF WBC/red blood cell count ratio (both p < 0.0001). Neither a temporal trend in potential predictors of CP-ERI nor a correlation between clinical diagnosis and proven CSF infection was found. CONCLUSIONS Clinicians base their diagnosis of ERI mostly on CSF analysis and occurrence of fever, leading to over-diagnosis. The accuracy of the clinical diagnosis is low. Commonly used clinical and laboratory diagnostic criteria have a low sensitivity and specificity for ERI.
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Evaluation of the Formation of Single- and Double-Species Biofilms on Intraventricular Catheters by Strains of Staphylococcus aureus, Listeria monocytogenes and Escherichia coli with K1 Antigen. Jundishapur J Microbiol 2018. [DOI: 10.5812/jjm.62323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Impact of an External Ventricular Drain Placement and Handling Protocol on Infection Rates: A Meta-Analysis and Single Institution Experience. World Neurosurg 2018; 115:e53-e58. [DOI: 10.1016/j.wneu.2018.03.160] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 11/21/2022]
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Darrow DP, Quinn C, Do TH, Hunt M, Haines S. Creation of an External Ventricular Drain Registry from a Quality Improvement Project. World Neurosurg 2018; 114:84-89. [DOI: 10.1016/j.wneu.2018.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/03/2018] [Indexed: 11/15/2022]
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Thompson DR, Vlachos S, Patel S, Innocent S, Tolias C, Barkas K. Recurrent sampling and ventriculostomy-associated infections: a case-control study. Acta Neurochir (Wien) 2018. [PMID: 29541885 DOI: 10.1007/s00701-018-3508-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND External ventricular drain (EVD) insertion is a common neurosurgical procedure with a significant risk of ventriculostomy-associated infections (VAIs), other morbidities and mortality. Several risk factors have been identified but their effect is unclear. OBJECTIVE Our primary objective was to assess whether recurrent EVD sampling increased the risk of VAIs. The secondary objective was to explore the effect of sampling frequency, duration of EVD stay, presence of cerebrospinal fluid leak and concurrent infections. METHODS Ours was a retrospective, single-centre, age-matched, case control study of 83 patients and 249 controls who underwent EVD insertion between 1 January 2010 - 31 December 2016. Patients with primary CNS infections, age under 1 year and death within 5 days of EVD insertion were excluded. Blinded abstractors collected all patient data through the electronic patient record system and regression analysis was used to compare the two groups. RESULTS Sampling the EVD more than once did not increase the risk of infection (OR 0.47, 95% CI 0.27-0.83, p = 0.01). Risk factors significantly associated with VAI included CSF leak (OR 2.06, 95% CI 1.16-3.67, p = 0.01), concurrent infection (OR 1.85, 95% CI 1.09-3.16, p = 0.02), and an EVD duration of >10 days (OR 2.28, 95% CI 1.24-4.18, p = 0.01). CONCLUSION Our findings do not support the notion that increased sampling of EVDs is associated with a higher risk of VAI. CSF leaks, concurrent infection and long-term EVDs are also statistically significant risk factors for infection.
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Health Care-Associated Infections after Subarachnoid Hemorrhage. World Neurosurg 2018; 115:e393-e403. [PMID: 29678711 DOI: 10.1016/j.wneu.2018.04.061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Health care-associated infections (HAIs) after subarachnoid hemorrhage (SAH) are prevalent; however, data describing epidemiology of infection are limited. This study reports incidence rates, risk factors, and the resulting SAH patient-related outcomes. METHODS We studied the incidence of HAIs acquired in the intensive care unit (ICU) over a 6-year period. We used Bayesian Model Averaging to identify risk factors associated with an increased risk of HAIs, particularly urinary tract infections (UTI), pneumonia, and ventriculostomy-associated infections (VAI). We also examined the impact of HAIs on risk of vasospasm, ICU and hospital length of stay, and discharge disposition and adjusted for other risk factors. RESULTS Of 419 patients with SAH, 66 (15.8%) developed 79 HAI episodes. Mean HAI incidence rates (per 1000 ICU-days) were UTI, 7.1; pneumonia, 4.3; and VAI, 2.4. The admission characteristic associated with increased risk of overall HAI, UTI, and VAI was diabetes mellitus. Hunt and Hess grades III-V were associated with increased risk of overall HAI and VAI. Male gender, intraventricular hemorrhage, and blood glucose level (>10) were associated with increased risk of pneumonia, whereas the incidence was lower in the presence of steroids. HAI was associated with increased length of stay of 10 ICU-days and 22 hospital-days, but not vasospasm or poor discharge disposition. CONCLUSIONS HAIs are serious complications after SAH associated with prolonged ICU and hospital length of stay. Additional rigorous infection control measures aimed at patients with identifiable risk factors should trigger prevention, and early detection of nosocomial infections is warranted to further reduce the prevalence of HAIs.
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Strahm C, Albrich WC, Zdravkovic V, Schöbi B, Hildebrandt G, Schlegel M. Infection Rate after Cranial Neurosurgical Procedures: A Prospective Single-Center Study. World Neurosurg 2018; 111:e277-e285. [DOI: 10.1016/j.wneu.2017.12.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
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Park J, Choi YJ, Ohk B, Chang HH. Cerebrospinal Fluid Leak at Percutaneous Exit of Ventricular Catheter as a Crucial Risk Factor for External Ventricular Drainage–Related Infection in Adult Neurosurgical Patients. World Neurosurg 2018; 109:e398-e403. [DOI: 10.1016/j.wneu.2017.09.190] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022]
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Borgert M, Binnekade J, Paulus F, Goossens A, Dongelmans D. A flowchart for building evidence-based care bundles in intensive care: based on a systematic review. Int J Qual Health Care 2017; 29:163-175. [PMID: 28453823 DOI: 10.1093/intqhc/mzx009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/23/2017] [Indexed: 01/22/2023] Open
Abstract
Purpose The Institute for Healthcare Improvement is the founder of the care bundled approach and described the methods used on how to develop care bundles. However, other useful methods are published as well. In this systematic review, we identified what different methods were used to design care bundles in intensive care units. The results were used to build a comprehensive flowchart to guide through the care bundle design process. Data sources Electronic databases were searched for eligible studies in PubMed, EMBASE and CINAHL from January 2001 to August 2014. Study selection There were no restrictions on the types of study design eligible for inclusion. Methodological quality was assessed by using the Downs & Black-checklist or Appraisal of Guidelines, REsearch and Evaluation II. Data extraction Data extraction was independently performed by two reviewers. Results of data synthesis A total of 4665 records were screened and 18 studies were finally included. The complete process of designing bundles was reported in 33% (6/18). In 50% (9/18), one of the process steps was described. A narrative report was written about care bundles in general in 17% (3/18). We built a comprehensive flowchart to visualize and structure the process of designing care bundles. Conclusion We identified useful methods for designing evidence-based care bundles. We built a comprehensive flowchart to provide an overview of the methods used to design care bundles so that others could choose their own applicable method. It guides through all necessary steps in the process of designing care bundles.
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Affiliation(s)
- Marjon Borgert
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Jan Binnekade
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Astrid Goossens
- Department of Quality Assurance and Process Innovation, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Dave Dongelmans
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
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Woo PY, Wong HT, Pu JK, Wong WK, Wong LY, Lee MW, Yam KY, Lui WM, Poon WS. Moving the goalposts: A comparison of different definitions for primary external ventricular drain infection and its risk factors: A multi-center study of 2575 patients. J Clin Neurosci 2017; 45:67-72. [DOI: 10.1016/j.jocn.2017.05.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/22/2017] [Indexed: 12/01/2022]
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Flint AC, Toossi S, Chan SL, Rao VA, Sheridan W. A Simple Infection Control Protocol Durably Reduces External Ventricular Drain Infections to Near-Zero Levels. World Neurosurg 2017; 99:518-523. [DOI: 10.1016/j.wneu.2016.12.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 12/08/2016] [Accepted: 12/10/2016] [Indexed: 11/26/2022]
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Trends in Ventriculostomy-Associated Infections and Mortality in Aneurysmal Subarachnoid Hemorrhage: Data From the Nationwide Inpatient Sample. World Neurosurg 2017; 99:599-604. [DOI: 10.1016/j.wneu.2016.12.073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/15/2016] [Accepted: 12/17/2016] [Indexed: 10/20/2022]
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Humphreys H, Jenks P, Wilson J, Weston V, Bayston R, Waterhouse C, Moore A. Surveillance of infection associated with external ventricular drains: proposed methodology and results from a pilot study. J Hosp Infect 2017; 95:154-160. [DOI: 10.1016/j.jhin.2016.09.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022]
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Baum GR, Hooten KG, Lockney DT, Fargen KM, Turan N, Pradilla G, Murad GJA, Harbaugh RE, Glantz M. External ventricular drain practice variations: results from a nationwide survey. J Neurosurg 2017; 127:1190-1197. [PMID: 28084912 DOI: 10.3171/2016.9.jns16367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While guidelines exist for many neurosurgical procedures, external ventricular drain (EVD) insertion has yet to be standardized. The goal of this study was to survey the neurosurgical community and determine the most frequent EVD insertion practices. The hypothesis was that there would be no standard practices identified for EVD insertion or methods to avoid EVD-associated infections. METHODS The American Association of Neurological Surgeons membership database was queried for all eligible neurosurgeons. A 16-question, multiple-choice format survey was created and sent to 7217 recipients. The responses were collected electronically, and the descriptive results were tabulated. Data were analyzed using the chi-square test. RESULTS In total, 1143 respondents (15.8%) completed the survey, and 705 respondents (61.6%) reported tracking EVD infections at their institution. The most common self-reported infection rate ranged from 1% to 3% (56.1% of participants), and 19.7% of respondents reported a 0% infection rate. In total, 451 respondents (42.7%) indicated that their institution utilizes a formal protocol for EVD placement. If a respondent's institution had a protocol, only 258 respondents (36.1%) always complied with the protocol. Protocol utilization for EVD insertion was significantly more frequent among residents, in academic/hybrid centers, in ICU settings, and if the institution tracked EVD-associated infection rates (p < 0.05). A self-reported 0% infection rate was significantly more commonly associated with a higher level of training (e.g., attending physicians), private center settings, a clinician performing 6 to 10 EVD insertions within the previous 12 months, and prophylactic continuous antibiotic utilization (p < 0.05). CONCLUSIONS This survey demonstrated heterogeneity in the practices for EVD insertion. No standard practices have been proposed or adopted by the neurosurgical community for EVD insertion or complication avoidance. These results highlight the need for the nationwide standardization of technique and complication prevention measures.
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Affiliation(s)
- Griffin R Baum
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kristopher G Hooten
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
| | - Dennis T Lockney
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
| | - Kyle M Fargen
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Nefize Turan
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gustavo Pradilla
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Gregory J A Murad
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida
| | - Robert E Harbaugh
- Department of Neurosurgery, Penn State University School of Medicine, Hershey, Pennsylvania
| | - Michael Glantz
- Department of Neurosurgery, Penn State University School of Medicine, Hershey, Pennsylvania
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Cinibulak Z, Aschoff A, Apedjinou A, Kaminsky J, Trost HA, Krauss JK. Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany. Acta Neurochir (Wien) 2016; 158:847-53. [PMID: 26928728 DOI: 10.1007/s00701-016-2747-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 02/16/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND There are various recommendations, but no generally accepted guidelines, to reduce the risk of external ventricular drainage (EVD)-associated infections. The primary objective of the present study was to evaluate the current practice of EVD in a European country and to set the results in perspective to published data. METHOD A standardised questionnaire prepared by the Commission of Technical Standards and Norms of the German Society of Neurosurgery was sent to 127 neurosurgical units in Germany. RESULTS Data were analysed from 99 out of 127 neurosurgical units which had been contacted. Overall, more than 10,000 EVD procedures appear to be performed in Germany annually. There is disagreement about the location where the EVD is inserted, and most EVDs are still inserted in the operation theatre. Most units apply subcutaneous tunnelling. Impregnated EVD catheters are used regularly in only about 20 % of units. Single-shot antibiotic prophylaxis is given in more than half of the units, while continued antibiotic prophylaxis is installed in only 15/99 units at a regular basis. There are discrepancies in the management of prolonged EVD use with regard to replacement policies. Regular cerebrospinal fluid (CSF) sampling is still performed widely. There were no statistical differences in policies with regard to academic versus non-academic units. CONCLUSIONS This survey clearly shows that some newer recommendations drawn from published studies penetrate much slower into clinical routine, such as the use of impregnated catheters, for example. It remains unclear how different policies actually impact quality and outcome in daily routine.
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Affiliation(s)
- Zafer Cinibulak
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Str. 1, 30625, Hannover, Germany.
- Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356, Leipzig, Germany.
| | - Alfred Aschoff
- Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356, Leipzig, Germany
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Anani Apedjinou
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Str. 1, 30625, Hannover, Germany
| | - Jan Kaminsky
- Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356, Leipzig, Germany
- Department of Neurosurgery, Sankt Gertrauden Hospital, Berlin, Germany
| | - Hans A Trost
- Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356, Leipzig, Germany
- Department of Neurosurgery, Bayreuth Hospital, Bayreuth, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Str. 1, 30625, Hannover, Germany
- Commission of Technical Standards and Norms, German Society of Neurosurgery, Messe-Allee 1, 04356, Leipzig, Germany
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Ventriculostomy related infection in intensive care unit: Diagnostic criteria and related conditions. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Dasenbrock HH, Bartolozzi AR, Gormley WB, Frerichs KU, Aziz-Sultan MA, Du R. Clostridium difficile Infection After Subarachnoid Hemorrhage. Neurosurgery 2016; 78:412-20. [DOI: 10.1227/neu.0000000000001065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, Guanci MM, Seder DB, Singh JM. The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement. Neurocrit Care 2016; 24:61-81. [DOI: 10.1007/s12028-015-0224-8] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Infektionsschutz und spezielle Hygienemaßnahmen in klinischen Disziplinen. KRANKENHAUS- UND PRAXISHYGIENE 2016. [PMCID: PMC7152143 DOI: 10.1016/b978-3-437-22312-9.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ducis K, Thakrar R, Tranmer B. Ventriculostomies without dressings: Low infection rates but room for quality improvement. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408615613099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Ventriculostomies are common procedures for patients with severe neurologic insults including trauma, aneurysmal rupture, tumor, infection or following an operation. Infection secondary to a ventriculostomy, meningitis or ventriculitis, carries a high morbidity and mortality. Insertion practices and maintenance of these interventions was evaluated. Methods A retrospective review was completed of patients receiving ventriculostomies at a single institution from October 2007 through September 2013. Basic patient demographics, methods of insertion and presence of infection were collected and analyzed. Results The mean of age of patients receiving ventriculostomies was 49 years of age and the most common indications for insertion were trauma, infection and nontraumatic intracranial hemorrhage (aneurysmal subarachnoid hemorrhage (SAH), hemorrhagic stroke, arteriovenous malformation (AVM)). External ventricular drains (EVDs) were inserted after minimal hair removal at the time of procedure, tunneling following procedure and securement of EVDs with suture at exit of skin and remainder of drain stapled to scalp without additional dressing applied. The infection rate using this practice was 5.1%. Conclusion Ventriculostomies with minimal hair removal and no dressing have equivalent infection rates with the most recent published national average.
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Affiliation(s)
- Katrina Ducis
- University of Vermont Medical Center, Burlington, VT, USA
| | - Raj Thakrar
- University of Vermont Medical Center, Burlington, VT, USA
| | - Bruce Tranmer
- University of Vermont Medical Center, Burlington, VT, USA
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Atkinson RA, Fikrey L, Vail A, Patel HC. Silver-impregnated external-ventricular-drain-related cerebrospinal fluid infections: a meta-analysis. J Hosp Infect 2015; 92:263-72. [PMID: 26601606 DOI: 10.1016/j.jhin.2015.09.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 09/16/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) infection is the primary complication associated with placement of an external ventricular drain (EVD). The use of silver-impregnated EVD catheters has become commonplace in many neurosurgical centres. AIM To assess the effect of silver-impregnated EVD catheter usage on catheter-related CSF infections. METHODS A meta-analysis was performed by systematically searching Medline, Embase and the Cochrane Library. All randomized controlled trials (RCTs) and non-RCTs comparing silver-impregnated and plain EVD catheters were identified and analysed. FINDINGS Six non-RCTs were included. The crude infection rate was 10.8% for plain catheters and 8.9% for silver-impregnated catheters [pooled odds ratio (OR) 0.71, 95% confidence interval (CI) 0.46-1.08; P = 0.11]. In a microbiological spectrum analysis, silver-impregnated catheters demonstrated a significantly lower rate of CSF infections caused by Gram-positive organisms (2.0% vs 6.7% in the silver-impregnated and plain catheter groups, respectively; pooled OR 0.27, 95% CI 0.11-0.63; P = 0.002). CONCLUSION The antimicrobial effects of silver-impregnated EVD catheters may be selective, and may need to be evaluated further in a prospective, controlled manner.
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Affiliation(s)
- R A Atkinson
- Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford, UK; Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - L Fikrey
- Leiden University Medical Centre, Leiden, The Netherlands
| | - A Vail
- Centre for Biostatistics, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - H C Patel
- Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford, UK; Vascular and Stroke Centre, Institute of Cardiovascular Sciences, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK.
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Shekhar H, Kalsi P, Dambatta S, Strachan R. Do antibiotic-impregnated external ventriculostomy catheters have a low infection rate in clinical practice? A retrospective cohort study. Br J Neurosurg 2015; 30:64-9. [DOI: 10.3109/02688697.2015.1096903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bayston R, Ashraf W, Ortori C. Does release of antimicrobial agents from impregnated external ventricular drainage catheters affect the diagnosis of ventriculitis? J Neurosurg 2015; 124:375-81. [PMID: 26067618 DOI: 10.3171/2014.12.jns141900] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recently concern has arisen over the effect of released antimicrobial agents from antibiotic-impregnated external ventricular drainage (EVD) catheters on the reliability of CSF culture for diagnosis of ventriculitis. The authors designed a laboratory study to investigate this possibility, and to determine whether there was also a risk of loss of bacterial viability when CSF samples were delayed in transport to the laboratory. METHODS Three types of commercially available antibiotic-impregnated EVD catheters were perfused with a suspension of bacteria (Staphylococcus epidermidis) over 21 days. Samples were analyzed for bacterial viability and for concentrations of antibiotics released from the catheters. The authors also investigated the effect on bacterial viability in samples stored at 18°C and 4°C to simulate delay in CSF samples reaching the laboratory for analysis. RESULTS Bacterial viability was significantly reduced in all 3 catheter types when sampled on Day 1, but this effect was not observed in later samples. The results were reflected in stored samples, with significant loss of viability in Day 1 samples but with little further loss of viable bacteria in samples obtained after this time point. All samples stored for 18 hours showed significant loss of viable bacteria. CONCLUSIONS While there were differences between the catheters, only samples taken on Day 1 showed a significant reduction in the numbers of viable bacteria after passing through the catheters. This reduction coincided with higher concentrations of antimicrobial agents in the first few hours after perfusion began. Similarly, bacterial viability declined significantly after storage of Day 1 samples, but only slightly in samples obtained thereafter. The results indicate that drugs released from these antimicrobial catheters are unlikely to affect the diagnosis of ventriculitis, as sampling for this purpose is not usually conducted in the first 24 hours of EVD.
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Affiliation(s)
- Roger Bayston
- Biomaterials-Related Infection Group, School of Medicine, and
| | - Waheed Ashraf
- Biomaterials-Related Infection Group, School of Medicine, and
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Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA. Bleeding and infection with external ventricular drainage: a systematic review in comparison with adjudicated adverse events in the ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) trial. Neurosurgery 2015; 76:291-300; discussion 301. [PMID: 25635887 PMCID: PMC4333009 DOI: 10.1227/neu.0000000000000624] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication. OBJECTIVE To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature. METHODS Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software. RESULTS Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis. CONCLUSION Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites.
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Affiliation(s)
- Mahua Dey
- ‡Section of Neurosurgery and Neurovascular Surgery Program, Division of Biological Sciences and the Pritzker School of Medicine, University of Chicago, Chicago, Illinois; §Pritzker School of Medicine, University of Chicago, Chicago, Illinois; ¶Johns Hopkins Medicine, Baltimore, Maryland; ‖Boston Medical Center, Boston, Massachusetts; #Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; **University of Maryland, Baltimore, Maryland; ‡‡Thomas Jefferson University, Philadelphia, Pennsylvania; §§University of Alberta, Edmonton, Alberta, Canada; ¶¶Stanford University, Stanford, California
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