Detailed standardized protocol to prevent cerebrospinal fluid shunt infection

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While cerebrospinal fluid (CSF) shunt surgery plays an essential role in the treatment of hydrocephalus, postoperative infection due to the implantation of foreign materials is still one of the most common and potentially serious complications of this procedure. Because no previously reported protocol has been proven to prevent postoperative infection after CSF shunt surgeries in adults, the authors investigated the effectiveness of a protocol introduced in their institution.


A detailed standardized surgical protocol to prevent infection in patients undergoing CSF shunt surgeries was introduced in the authors’ institution in December 2011. The protocol included a series of detailed rules regarding the surgical procedure, the surgical environment to minimize contamination from air, double gloving, local injection of antibiotics, and postoperative management. The rate of CSF shunt infection during the 3 years after surgery before and after implementation of the protocol was compared in patients undergoing their first CSF shunt surgeries. The inclusion periods were from January 2006 to November 2011 for the preprotocol group and from December 2011 to December 2014 for the postprotocol group.


The study included 124 preprotocol patients and 52 postprotocol patients. The mean patient age was 59 years in both groups, ranging from 40 days to 88 years. Comparison of patient background factors, including known risk factors for surgical site infections, showed no significant difference between the patient groups before and after implementation of the protocol. While 9 patients (7.3%) developed shunt infections before protocol implementation, no shunt infections (0%) were observed in patients who underwent surgery after protocol implementation. The difference was statistically significant (p = 0.047).


The authors’ detailed protocol for CSF shunt surgeries was effective in preventing postoperative infection regardless of patient age.

ABBREVIATIONS CSF = cerebrospinal fluid; SSI = surgical site infection.

Article Information

Correspondence Keisuke Maruyama: Kyorin University, Tokyo, Japan.

INCLUDE WHEN CITING Published online February 15, 2019; DOI: 10.3171/2018.10.JNS181432.

Y.O. and K.M. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Flow diagram showing protocol to prevent infection after CSF shunt surgery. Asterisk indicates procedures that we originated. CEZ = cephazoline; GM = gentamycin; IV = intravenously; VCM = vancomycin.



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