Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis

Treatment Effects in Randomized and Nonrandomized Studies of Pharmacological Interventions: A Meta-Analysis

Importance

Randomized clinical trials (RCTs) are widely regarded as the methodological benchmark for assessing clinical efficacy and safety of health interventions. There is growing interest in using nonrandomized studies to assess efficacy and safety of new drugs.

Objective

To determine how treatment effects for the same drug compare when evaluated in nonrandomized vs randomized studies.

Data Sources

Meta-analyses published between 2009 and 2018 were identified in MEDLINE via PubMed and the Cochrane Database of Systematic Reviews. Data analysis was conducted from October 2019 to July 2024.

Study Selection

Meta-analyses of pharmacological interventions were eligible for inclusion if both randomized and nonrandomized studies contributed to a single meta-analytic estimate.

Data Extraction and Synthesis

For this meta-analysis using a meta-epidemiological framework, separate summary effect size estimates were calculated for nonrandomized and randomized studies within each meta-analysis using a random-effects model and then these estimates were compared. The reporting of this study followed the Guidelines for Reporting Meta-Epidemiological Methodology Research and relevant portions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcome and Measures

The primary outcome was discrepancies in treatment effects obtained from nonrandomized and randomized studies, as measured by the proportion of meta-analyses where the 2 study types disagreed about the direction or magnitude of effect, disagreed beyond chance about the effect size estimate, and the summary ratio of odds ratios (ROR) obtained from nonrandomized vs randomized studies combined across all meta-analyses.

Results

A total of 346 meta-analyses with 2746 studies were included. Statistical conclusions about drug benefits and harms were different for 130 of 346 meta-analyses (37.6%) when focusing solely on either nonrandomized or randomized studies. Disagreements were beyond chance for 54 meta-analyses (15.6%). Across all meta-analyses, there was no strong evidence of consistent differences in treatment effects obtained from nonrandomized vs randomized studies (summary ROR, 0.95; 95% credible interval [CrI], 0.89-1.02). Compared with experimental nonrandomized studies, randomized studies produced on average a 19% smaller treatment effect (ROR, 0.81; 95% CrI, 0.68-0.97). There was increased heterogeneity in effect size estimates obtained from nonrandomized compared with randomized studies.

Conclusions and Relevance

In this meta-analysis of treatment effects of pharmacological interventions obtained from randomized and nonrandomized studies, there was no overall difference in effect size estimates between study types on average, but nonrandomized studies both overestimated and underestimated treatment effects observed in randomized studies and introduced additional uncertainty. These findings suggest that relying on nonrandomized studies as substitutes for RCTs may introduce additional uncertainty about the therapeutic effects of new drugs.

The Landscape of Pediatric Hydrocephalus in the Province of KwaZulu-Natal: A Comparative Analysis of the Referral Pattern, Etiology, and Management Outcomes in 4 Distinct 5-Year Periods

BACKGROUND

Pediatric hydrocephalus is a significant health burden globally, particularly in low- and middle-income countries. Data from specific regions such as KwaZulu-Natal, South Africa, are lacking. This study aimed to investigate pediatric hydrocephalus by comparing 4 distinct 5-year periods.

METHODS

Data were collected retrospectively (2003-2007, 2008-2012, and 2013-2017) and prospectively (2018-2022). Children (≤18 years old) treated for hydrocephalus were included. Data on demographics, referral patterns, etiology, treatment modalities, and outcomes were collected and analyzed.

RESULTS

A total of 3325 children were treated. The peak period was 2008-2012 (35.3%). Most children (51.4%) were from rural areas (P = 0.013), and 47.9% were referred from regional hospitals (P < 0.001). Boys (56.4%) and infants (60.2%) were predominant groups (P < 0.001). Postinfectious etiology (32.7%) was predominant (P < 0.001), particularly tuberculous meningitis (54.1%). Ventriculoperitoneal shunts were the mainstay treatment (84.2%), with notable complication rates (20.4%), including infections (9.6%). Human immunodeficiency virus co-infection was diagnosed in 2.5% of cases. Weekend procedures were associated with ventriculoperitoneal shunt complications (hazard ratio [HR] = 1.3, 95% confidence [CI]1.03-1.66, P = 0.03). Mortality rate was 7.9%, and age ≥1 year (HR = 2.43, 95% CI 1.87-3.17, P < 0.001), tertiary hospital referral (HR = 1.48, 95% CI 1.06-2.04, P = 0.019), ventriculoperitoneal shunt infection (HR = 3.63, 95% CI 2.66-4.95, P < 0.001), acute abdomen (HR = 2.17, 95% CI 1.11-4.25, P = 0.024), and pneumonia (HR = 7.32, odds ratio = 4.84-11.06, P < 0.001) were associated with mortality.

CONCLUSIONS

This study provides comprehensive insights into pediatric hydrocephalus in KwaZulu-Natal. Monitoring temporal trends and predictors of outcomes will guide future interventions to mitigate the burden of pediatric hydrocephalus in the region.

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study

Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.

Cerebrospinal Fluid Shunt Infections in Children: Do Hematologic and Cerebrospinal Fluid White Cells Examinations Correlate With the Type of Infection?

BACKGROUND

Cerebrospinal fluid (CSF) shunt infections in children represent an increasing problem in clinical practice. However, comprehensive clinical, laboratory and microbiologic data are scarce in pediatric age.

METHODS

We conducted a 10-year retrospective study to (1) analyze clinical, laboratory and microbiologic parameters associated with infections in children; (2) analyze results according to the type of catheter (medicated or not), type of infection (first or relapses), type of hydrocephalus (acquired and congenital), presence or not of bacteriemia; (3) describe antibiotic susceptibilities and their evolution during the study period.

RESULTS

Eighty-seven children with shunt infection and 61 children with mechanical shunt malfunction were enrolled. Fever, vomit, leukocytosis and elevated C-reactive protein were more frequent in the infected group (P < 0.001), while neurologic symptoms developed more frequently in the noninfected group (10.3% vs. 27.87%; P = 0.006). Local signs of inflammation and abdomen distension were similarly reported in the 2 groups. Children with medicated shunts had lower cell count in the CSF (12/mm3) compared with those with nonmedicated shunts (380/mm3; P < 0.0001). Gram-negative bacteria were more common in the not-medicated catheters (90.91% vs. 50% of cultures; P = 0.04). Gram-negative bacteria were identified in 50.67% of CSF cultures, Gram-positive bacteria in 53.33% and fungi were observed in 5.33%. Sixteen children (18.4%) had also a positive blood culture. Enterococci isolation was associated with relapsed infections (37.50% vs. 15.25%; P = 0.05).

CONCLUSIONS

Our study shows that the diagnosis and management of children with shunt infections are challenging. Prospective studies with a comprehensive approach focusing on patient, medical, microbiologic and surgical risk factors for first infection are urgently needed.

Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020-21

Background

Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed.

Methods

In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation.

Results

The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues.

Conclusions

Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.

Risk factors for pediatric surgical site infection following neurosurgical procedures for hydrocephalus: a retrospective single-center cohort study

Background

Infection is a major complication following cerebral spinal fluid (CSF) diversion procedures for hydrocephalus. However, pediatric risk factors for surgical site infection (SSI) are currently not well defined. Because a SSI prevention bundle is increasingly introduced, the purpose of this study was to evaluate risk factors associated with SSIs following CSF diversion surgeries following a SSI bundle at a single quaternary care pediatric hospital.

Methods

We performed a retrospective cohort study of patients undergoing CSF diversion procedures from 2017 to 2019. SSIs were identified prospectively through continuous surveillance. We performed unadjusted logistic regression analyses and univariate analyses to determine an association between SSIs and patient demographics, comorbidities and perioperative factors to identify independent risk factors for SSI.

Results

We identified a total of 558 CSF diversion procedures with an overall SSI rate of 3.4%. The SSI rates for shunt, external ventricular drain (EVD) placement, and endoscopic third ventriculostomy (ETV) were 4.3, 6.9 and 0%, respectively. Among 323 shunt operations, receipt of clindamycin as perioperative prophylaxis and presence of cardiac disease were significantly associated with SSI (O.R. 4.99, 95% C.I. 1.27–19.70, p = 0.02 for the former, and O.R. 7.19, 95% C.I. 1.35–38.35, p = 0.02 for the latter). No risk factors for SSI were identified among 72 EVD procedures.

Conclusion

We identified receipt of clindamycin as perioperative prophylaxis and the presence of cardiac disease as risk factors for SSI in shunt procedures. Cefazolin is recommended as a standard antibiotic for perioperative prophylaxis. Knowing that unsubstantiated beta-lactam allergy label is a significant medical problem, efforts should be made to clarify beta-lactam allergy status to maximize the number of patients who can receive cefazolin for prophylaxis before shunt placement. Further research is needed to elucidate the mechanism by which cardiac disease may increase SSI risk after shunt procedures.

The Effectiveness of Antibiotic-Coated Ventriculoperitoneal Shunts for Prevention of Shunt Infections in Patients with Myelomeningocele

PURPOSE

Hydrocephalus is a common comorbidity among the newborns, with myelomeningocele (MMC) and ventriculoperitoneal (VP) shunts being frequently used for the treatment of such patients. In this study, we aimed to compare the effectiveness of antibiotic-free and antibiotic-coated shunts to reduce the rate of shunt infection in patients with hydrocephalus and accompanying MMC.

METHODS

116 patients with hydrocephalus and MMC who were treated with VP shunts were included in the study. Shunt infection rates among antibiotic-free and antibiotic-coated shunts were compared.

RESULTS

Of the 116 patients included in the study, 39 had antibiotic-coated shunts and 77 had antibiotic-free shunts. Shunt infection developed in 4 of the 39 cases treated with antibiotic-coated shunts and in 5 of the 77 cases treated with shunts without antibiotics. No significant statistical difference was found between antibiotic-coated and antibiotic-free VP shunts in terms of shunt infection (p = 0.450, p > 0.05).

CONCLUSION

In patients with MMC, using VP shunts containing antibiotics was found not to have a protective effect in preventing shunt infection. Whether the sac is intact or ruptured does not affect this result.

Ventriculoperitoneal shunt infection rates using a standard surgical technique, including topical and intraventricular vancomycin: the Children's Hospital Oakland experience

OBJECTIVE

Ventriculoperitoneal (VP) shunt infections are common complications after shunt operations. Despite the use of intravenous antibiotics, the incidence of infections remains high. Though antibiotic-impregnated catheters (AICs) are commonly used, another method of infection prophylaxis is the use of intraventricular (IVT) antibiotics. The authors describe their single-institution experience with a standard shunt protocol utilizing prophylactic IVT and topical vancomycin administration and report the incidence of pediatric shunt infections.

METHODS

Three hundred two patients undergoing VP shunt procedures with IVT and topical vancomycin between 2006 and 2016 were included. Patients were excluded if their age at surgery was greater than 18 years. Shunt operations were performed at a single institution following a standard shunt protocol implementing IVT and topical vancomycin. No AICs were used. Clinical data were retrospectively collected from the electronic health records.

RESULTS

Over the 11-year study period, 593 VP shunt operations were performed with IVT and topical vancomycin, and a total of 19 infections occurred (incidence 3.2% per procedure). The majority of infections (n = 10, 52.6%) were caused by Staphylococcus epidermidis. The median time to shunt infection was 3.7 weeks. On multivariate analysis, the presence of a CSF leak (OR 31.5 [95% CI 8.8-112.6]) and age less than 6 months (OR 3.6 [95% CI 1.2-10.7]) were statistically significantly associated with the development of a shunt infection. A post hoc analysis comparing infection rates after procedures that adhered to the shunt protocol and those that did not administer IVT and topical vancomycin, plus historical controls, revealed a difference in infection rates (3.2% vs 6.9%, p = 0.03).

CONCLUSIONS

The use of a standardized shunt operation technique that includes IVT and topical vancomycin is associated with a total shunt infection incidence of 3.2% per procedure, which compares favorably with the reported rates of shunt infection in the literature. The majority of infections occurred within 2 months of surgery and the most common causative organism was S. epidermidis. Young age (< 6 months) at the time of surgery and the presence of a postoperative CSF leak were statistically significantly associated with postoperative shunt infection on multivariate analysis. The results are hypothesis generating, and the authors propose that IVT and topical administration of vancomycin as part of a standardized shunt operation protocol may be an appropriate option for preventing pediatric shunt infections.

Efficacy of antibiotic-impregnated shunt versus conventional shunts to reduce cerebrospinal fluid infections in children: A systematic review and meta-analysis

Hydrocephalus is among the most common pediatric conditions treated by neurosurgeons. An antibiotic-impregnated shunt (AIS) was designed to reduce the rate of shunt infections. The objective of this systematic review and meta-analysis was to assess the efficiency of AIS in reducing the rate of shunt infection compared with standard shunts (SSs). A systematic search of PubMed, EMBASE, Medline, Cochrane Library, TRIP Database, CINAHL and Google Scholar databases was performed. Eligible studies included observational studies and randomized controlled trials (RCT) that compared the effects of AIS and SS for preventing shunt infections in pediatric patients. Twelve observational studies and one RCT conducted from January 2005 through October 2019 involving 7,952 pediatric patients were included in the analysis. The use of AIS significantly decreased the risk of CRI [risk ratio (RR) 0.42; 95% confidence interval: 0.33 to 0.53; P<0.00001] with no statistical heterogeneity across the included studies (I²=42%). This analysis demonstrates that the use of AIS significantly reduces the risk of shunt infection in pediatric patients.

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.

Topical instillation of vancomycin lowers the rate of CSF shunt infections in children

INTRODUCTION

Shunt surgery in pediatric patients still bears a significant risk of infection, in addition to mechanical complications of the shunt system. Antibiotic-impregnated systems and perioperative antibiotics have been extensively studied for their potential to reduce shunt infections. We examined the effectiveness of intrawound application of vancomycin powder during shunt surgery.

PATIENTS AND METHODS

Patient records of 78 primary shunt implantations at a mean age of 40 months were reviewed. In total, 52 patients (mean age 50 months) had been treated according to standard surgical and perioperative procedures (Std), whereas 26 patients (mean age 20 months) additionally had received topical application of vancomycin powder before wound closure (Vmc). Overall infection rate was 3.8%, in Std patients 5.8%, and in Vmc patients 0%. The rates of CSF fistula and revision surgery were similar in both groups (5.8% vs 8% and 23.1% vs. 30%, respectively).

CONCLUSION

To the best of our knowledge, this is the first report on topical vancomycin instillation, indicating its efficacy for the prevention of shunt infection in pediatric patients. Further studies with a higher number of patients are needed to verify this finding.

Route of antibiotic prophylaxis for prevention of cerebrospinal fluid-shunt infection

BACKGROUND

The main complication of cerebrospinal fluid (CSF) shunt surgery is shunt infection. Prevention of these shunt infections consists of the perioperative use of antibiotics that can be administered in five different ways: orally; intravenously; intrathecally; topically; and via the implantation of antibiotic-impregnated shunt catheters.

OBJECTIVES

To determine the effect of different routes of antibiotic prophylaxis (i.e. oral, intravenous, intrathecal, topical and via antibiotic-impregnated shunt catheters) on CSF-shunt infections in persons treated for hydrocephalus using internalised CSF shunts.

SEARCH METHODS

We conducted a systematic electronic search without restrictions on language, date or publication type. We performed the search on the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase, with the help of the Information Specialist of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. The search was performed in January 2018.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials that studied the effect of antibiotic prophylaxis, in any dose or administration route, for the prevention of CSF-shunt infection in patients that were treated with an internal cerebrospinal fluid shunt. Patients with external shunts were not eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included studies. We resolved disagreements by discussion or by referral to an independent researcher within our department when necessary. Analyses were also performed by at least two authors.

MAIN RESULTS

We included a total of 11 small randomised controlled trials, containing 1109 participants, in this systematic review. Three of these studies included solely children, and the remaining eight included participants of all ages. Most studies were limited to the evaluation of ventriculoperitoneal shunts. However, five studies included participants with ventriculoatrial shunts, of which one study contained four participants with a subduroperitoneal shunt. We judged four out of 11 (36%) trials at unclear risk of bias, while the remaining seven trials (64%) scored high risk of bias in one or more of the components assessed.We analysed all included studies in order to estimate the effect of antibiotic prophylaxis on the proportion of shunt infections regardless of administration route. Although the quality of evidence in these studies was low, there may be a positive effect of antibiotic prophylaxis on the number of participants who had shunt infections (RR 0.55, 95% CI 0.36 to 0.84), meaning a 55% reduction in the number of participants who had shunt infection compared with standard care or placebo.Within the different administration routes, only within intravenous administration of antibiotic prophylaxis there may be evidence of an effect on the risk of shunt infections (RR 0.55, 95% CI 0.33 to 0.90). However, this was the only route that contained more than two studies (8 studies; 797 participants). Evidence was uncertain for both, intrathecal administration of antibiotics (RR 0.73, 95% CI 0.28 to 1.93, 2 studies; 797 participants; low quality evidence) and antibiotic impregnated catheters (RR 0.36, 95% CI 0.10 to 1.24, 1 study; 110 participants; very low quality evidence) AUTHORS' CONCLUSIONS: Antibiotic prophylaxis may have a positive effect on lowering the number of participants who had shunt infections. However, the quality of included studies was low and the effect is not consistent within the different routes of administration that have been analysed. It is therefore uncertain whether prevention of shunt infection varies by different antibiotic agents, different administration routes, timing and doses; or by characteristics of patients, e.g. children and adults. The results of the review should be seen as hypothesis-generating rather than definitive, and the results should be confirmed in adequately powered trials or large multicentre studies in order to obtain high-quality evidence in the field of ventricular shunt infection prevention.

Association between improvement of clinical signs and decrease of ventricular volume after ventriculoperitoneal shunting in dogs with internal hydrocephalus

BACKGROUND

One of the remaining questions in treating dogs with internal hydrocephalus is the association between the decrease of ventricular volume and re-expansion of cerebral parenchyma with clinical improvement.

HYPOTHESIS

A decrease in ventricular volume and re-expansion of brain tissue occur after ventriculoperitoneal shunting (VPS). Clinical improvement defined by resolution of ≥1 clinical signs is associated with decreased size of cerebral ventricles and that the extent of change in ventricular size is associated with clinical improvement.

ANIMALS

Forty-five client-owned dogs with newly diagnosed communicating internal hydrocephalus.

METHODS

Ventricular volume, brain volume, and clinical status of dogs that underwent VPS were measured before and 3 months after surgery. Multiple logistic regression analysis was performed to assess the influence of decrease in ventricular size in addition to the covariates "age of the animal" and "duration of clinical signs before surgery" on improvement of clinical signs.

RESULTS

Decreased volume of cerebral ventricles was associated with resolution of ≥1 preoperative clinical sign (P < .003). The covariates "age of the animal" and "duration of clinical signs" were not associated with improvement of clinical signs. The percentage decrease in ventricular size was associated with resolution of ataxia (P = .008) and obtundation (P = .011).

CONCLUSION AND CLINICAL IMPORTANCE

The decrease in ventricular volume and increase in brain parenchyma after VPS are associated with improvement in clinical signs.

Prophylactic antibiotics in pediatric neurological surgery

PURPOSE

Surgical antibiotic prophylaxis (SAP) in pediatric neurosurgery has poorly been characterized until now. This review gives an overview on the current literature extracting recommendations and guidelines.

METHODS

The current literature on SAP with special forcus on pediatric neurosurgerical procedures was reviewed. Further, available recommendations in online databases were checked. Clean neurosurgical, shunt, and implant surgeries are considered separately.

RESULTS

To date, evidence-based data on SAP in pediatric neurosurgery remain sparse and there are no standardized approaches to an adequate use of antimicrobial agents for SSI prevention for this age group.

CONCLUSION

Due to statistical needs, multi-center surveillance studies are needed for implementing SAP recommendations in pediatric neurosurgery.

Topical vancomycin reduces the cerebrospinal fluid shunt infection rate: A retrospective cohort study

Object

Despite many efforts at reduction, cerebrospinal fluid (CSF) shunt infections are a major cause of morbidity in shunt surgery, occurring in 5–15% of cases. To attempt to reduce the shunt infection rate at our institution, we added topical vancomycin (intrashunt and perishunt) to our existing shunt infection prevention protocol in 2012.

Methods

We performed a retrospective cohort study comparing all shunted patients in January 2010 to December 2011 without vancomycin (control group, 263 procedures) to all patients who underwent shunt surgery between April 2012 and December 2015 with vancomycin (intervention group, 499 procedures).

Results

The overall shunt infection rate significantly decreased from 6.8% (control group) to 3.0% (intervention group) (p = 0.023, absolute risk reduction 3.8%, relative risk reduction 56%). Multivariate logistic regression analysis confirmed that the addition of topical vancomycin showed that cases treated under a protocol of topical vancomycin were associated with a decreased shunt infection rate (odds ratio [OR] 0.49 95% CI 0.25–0.998; p = 0.049). Age < 1 year was associated with an increased risk of infection (OR) 4.41, 95% CI 2,10–9,26; p = 0.001). Time from surgery to infection was significantly prolonged in the intervention group (p = 0.001).

Conclusion

Adding intraoperative vancomycin to a shunt infection prevention protocol significantly reduces CSF shunt infection rate.

Treatment of abdominal pseudocysts and associated ventricuoperitoneal shunt failure

PURPOSE

The purpose of this study was to determine whether drainage and revision are an effective treatment for abdominal pseudocyst associated ventriculoperitoneal (VP) shunt failure by estimating the total rate of secondary shunt failure.

METHODS

We performed a retrospective review of children with hydrocephalus diagnosed with and treated for an abdominal pseudocyst at the Children's Hospital, London Health Sciences Centre (LHSC) between January 1, 2000 and May 31, 2016 (ethics approval # 108136). Patients with a VP shunt were included if (i) the development of an abdominal pseudocyst at age 2 to 18 years was identified, (ii) treatment of the pseudocyst by either interventional radiology (IR) or surgical drainage, and (iii) revision of the VP shunt. Demographic data and details of pseudocyst formation/ treatment as well as subsequent failures were identified.

RESULTS

Twelve patients who had a VP shunt developed abdominal pseudocyst and met inclusion criteria. A 91% shunt failure rate after drainage and shunt revision was identified. Three patients had the pseudocyst drained in interventional radiology and then externalized due to shunt infection. Nine patients were treated by surgical revision. Ten patients experienced recurrent shunt failure following initial drainage of the pseudocyst: pseudocyst reoccurrence (n = 3), distal obstruction from adhesions (n = 1), and uncleared infection (n = 6).

CONCLUSION

The results suggest that pseudocyst drainage and shunt revision is ineffective in providing long-term resolution of shunt problems.

The role of simultaneous abdominal surgery and wound classification in ventriculoperitoneal shunt complication

PURPOSE

To evaluate whether simultaneous abdominal surgery or wound contamination at the time of ventriculoperitoneal (VP) shunt placement are associated with increased shunt complications.

METHODS

Pediatric patients who underwent VP shunt placement were identified using the National Surgical Quality Improvement Program Pediatric database. VP shunt complication rates were compared between patients who underwent simultaneous abdominal surgeries at the time of VP shunt placement vs those who did not and between those with clean/clean-contaminated and contaminated/dirty wound classifications. Adjusted analysis was performed using 1:5 case-control matching.

RESULTS

Among 2715 patients who underwent VP shunt placement, 21 had simultaneous abdominal procedures and were matched with 105 control patients. No significant difference was found in overall (34.3 vs 14.3%, p = 0.07), infectious (8.6 vs 4.8%, p = 1.000), or non-infectious (25.7 vs 9.5%, p = 0.156) shunt complications in the simultaneous vs non-simultaneous group, respectively. In a separate analysis of wound classification, 12 patients with contaminated/dirty wounds were matched with 60 patients with clean/clean-contaminated wounds. The rates of shunt infections for clean/clean-contaminated and contaminated/dirty cases were 10.0 and 16.7%, respectively (p = 0.613).

CONCLUSION

In our matched case-control study, neither simultaneous abdominal surgery nor wound contamination at the time of VP shunt placement demonstrated significant increased risk of 30-day post-operative complication.

The Impact of a Pediatric Shunt Surgery Checklist on Infection Rate at a Single Institution

BACKGROUND

Shunt infections remain a significant challenge in pediatric neurosurgery. Numerous surgical checklists have been introduced to reduce infection rates.

OBJECTIVE

To introduce an evidence-based shunt surgery checklist and its impact on our shunt infection rate.

METHODS

Between January 1, 2008 and December 31, 2015, pediatric patients who underwent shunt surgery at our institution were indexed in a prospectively maintained database. All definitive shunt procedures were included. Shunt infection was defined according to the Center for Disease Control and Prevention's National Hospital Safety Network surveillance definition for surgical site infection. Clinical and procedural variables were abstracted per procedure. Infection data were compared for the 4 year before and 4 year after protocol implementation. Compliance was calculated from retrospective review of our checklists.

RESULTS

Over the 8-year study period, 1813 procedures met inclusion criteria with a total of 37 shunt infections (2%). Prechecklist (2008-2011) infection rate was 3.03% (28/924) and decreased to 1.01% (9/889; P = .003) postchecklist (2012-2015), representing an absolute risk reduction of 2.02% and relative risk reduction of 66.6%. One shunt infection was prevented for every 50 times the checklist was used. Those patients who developed an infection after protocol implementation were younger (0.95 years vs 3.40 years (P = .027)), but there were no other clinical or procedural variables, including time to infection, that were significantly different between the cohorts. Average compliance rate among required checklist components was 97% (range 85%-100%).

CONCLUSION

Shunt surgery checklist implementation correlated with lower infection rates that persisted in the 4 years after implementation.

Ventriculoperitoneal shunts in neonates: a retrospective study of outcomes with antibiotic-impregnated catheters and a modified peri-operative antibiotic protocol

BACKGROUND

CSF infection is a significant complication of ventriculoperitoneal (VP) shunts and results in prolonged hospital stay, developmental delay and decreased quality of life. To decrease the high rates of neonatal VP shunt infections, an updated clinical guideline that included the use of antibiotic-impregnated shunts and a revised peri-operative antibiotic protocol was introduced in our neonatal unit. In this study, we evaluated the efficacy of these new guidelines in reducing the CSF shunt infection rates.

METHODS

A retrospective cohort study of neonates (≤28 days) who had VP shunt insertions in our unit.

RESULTS

24 neonates in the first epoch received plain silastic shunt catheters (Feb 2002-April 2007), and 23 in the second epoch (August 2007-July 2015) received AIS catheters and a revised perioperative antibiotic protocol. Patient demographics were similar between both cohorts. Shunt related CSF infections were reduced in epoch 2 (2/23, 8.7%) compared to epoch 1 (5/24, 20.8%), but the results were not statistically significant (OR 0.36 (0.063-2.090); p = 0.256). Amongst neonates that needed VP shunt revision due to any cause, the median time interval between insertion to revision was significantly later in epoch 2 (epoch 1, 48 days (3-99); epoch 2, 148 days (20-396); p = 0.013).

CONCLUSIONS

AIS catheters and a 48-hour perioperative antibiotic regimen may be beneficial in neonatal hydrocephalus. Adequately powered RCTs in the neonatal population are needed to confirm these findings.

Risk of failure in pediatric ventriculoperitoneal shunts placed after abdominal surgery

OBJECTIVE Experience has led us to suspect an association between shunt malfunction and recent abdominal surgery, yet information about this potential relationship has not been explored in the literature. The authors compared shunt survival in patients who underwent abdominal surgery to shunt survival in our general pediatric shunt population to determine whether such a relationship exists. METHODS The authors performed a retrospective review of all cases in which pediatric patients underwent ventriculoperitoneal shunt operations at their institution during a 7-year period. Survival time in shunt operations that followed abdominal surgery was compared with survival time of shunt operations in patients with no history of abdominal surgery. Univariate and multivariate analyses were used to identify factors associated with failure. RESULTS A total of 141 patients who underwent 468 shunt operations during the period of study were included; 107 of these 141 patients had no history of abdominal surgery and 34 had undergone a shunt operation after abdominal surgery. Shunt surgery performed more than 2 weeks after abdominal surgery was not associated with time to shunt failure (p = 0.86). Shunt surgery performed within 2 weeks after abdominal surgery was associated with time to failure (adjusted HR 3.6, 95% CI 1.3-9.6). CONCLUSIONS Undergoing shunt surgery shortly after abdominal surgery appears to be associated with shorter shunt survival. When possible, some patients may benefit from shunt placement utilizing alternative termini.

Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines

OBJECTIVE

The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty.

METHODS

The authors first performed a PubMed search for "Neurosurgery" and "Guidelines." This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics.

RESULTS

When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P < 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered "Level 1" recommendations.

CONCLUSION

Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: Introduction and methodology

This clinical systematic review of and evidence-based guidelines for the treatment of pediatric hydrocephalus were developed by a physician volunteer task force. They are provided as an educational tool based on an assessment of current scientific and clinical information as well as accepted approaches to treatment. They are not intended to be a fixed protocol, because some patients may require more or less treatment. In Part 1, the authors introduce the reader to the complex topic of hydrocephalus and the lack of consensus on its appropriate treatment. The authors describe the development of the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force charged with reviewing the literature and recommending treatments for hydrocephalus, and they set out the basic methodology used throughout the specific topics covered in later chapters.