Detailed standardized protocol to prevent cerebrospinal fluid shunt infection

Restricted access

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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. kskmaru-tky@umin.ac.jp.

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.

Headings

Figures

  • 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.

References

  • 1

    Anderson DJKaye KSClassen DArias KMPodgorny KBurstin H: Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 29 (Suppl 1):S51S612008

    • Search Google Scholar
    • Export Citation
  • 2

    Anderson DJPodgorny KBerríos-Torres SIBratzler DWDellinger EPGreene L: Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 35 (Suppl 2):S66S882014

    • Search Google Scholar
    • Export Citation
  • 3

    Attenello FJGarces-Ambrossi GLZaidi HASciubba DMJallo GI: Hospital costs associated with shunt infections in patients receiving antibiotic-impregnated shunt catheters versus standard shunt catheters. Neurosurgery 66:2842892010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Beckman JMAmankwah EKTetreault LLTuite GF: Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure. J Neurosurg Pediatr 16:6486612015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Berríos-Torres SIUmscheid CABratzler DWLeas BStone ECKelz RR: Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 152:7847912017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Chen LFVander Weg MWHofmann DAReisinger HS: The Hawthorne Effect in infection prevention and epidemiology. Infect Control Hosp Epidemiol 36:144414502015

  • 7

    Choksey MSMalik IA: Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 75:87912004

  • 8

    Choux MGenitori LLang DLena G: Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:8758801992

  • 9

    Haynes ABWeiser TGBerry WRLipsitz SRBreizat AHDellinger EP: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:4914992009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Hommelstad JMadsø AEide PK: Significant reduction of shunt infection rate in children below 1 year of age after implementation of a perioperative protocol. Acta Neurochir (Wien) 155:5235312013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kanev PMSheehan JM: Reflections on shunt infection. Pediatr Neurosurg 39:2852902003

  • 12

    Kestle JRHolubkov RDouglas Cochrane DKulkarni AVLimbrick DD JrLuerssen TG: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 17:3913962016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kestle JRRiva-Cambrin JWellons JC IIIKulkarni AVWhitehead WEWalker ML: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 8:22292011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Konstantelias AAVardakas KZPolyzos KATansarli GSFalagas ME: Antimicrobial-impregnated and -coated shunt catheters for prevention of infections in patients with hydrocephalus: a systematic review and meta-analysis. J Neurosurg 122:109611122015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Korinek AMFulla-Oller LBoch ALGolmard JLHadiji BPuybasset L: Morbidity of ventricular cerebrospinal fluid shunt surgery in adults: an 8-year study. Neurosurgery 68:9859952011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kulkarni AVDrake JMLamberti-Pasculli M: Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:1952012001

  • 17

    Kulkarni AVShams I: Quality of life in children with hydrocephalus: results from the Hospital for Sick Children, Toronto. J Neurosurg 107 (5 Suppl):3583642007

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mangram AJHoran TCPearson MLSilver LCJarvis WR: Guideline for Prevention of Surgical Site Infection, 1999. Am J Infect Control 27:97134 961999

    • Search Google Scholar
    • Export Citation
  • 19

    Mayo E: The Human Problems of an Industrial Civilization. New York: Macmillan1933

  • 20

    Pirotte BJLubansu ABruneau MLoqa CVan Cutsem NBrotchi J: Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst 23:125112612007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Prusseit JSimon Mvon der Brelie CHeep AMolitor EVolz S: Epidemiology, prevention and management of ventriculoperitoneal shunt infections in children. Pediatr Neurosurg 45:3253362009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Raffa GMarseglia LGitto EGermanò A: Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants. Childs Nerv Syst 31:112911382015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Ragel BTBrowd SRSchmidt RH: Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:2422472006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Rehman AURehman TUBashir HHGupta V: A simple method to reduce infection of ventriculoperitoneal shunts. J Neurosurg Pediatr 5:5695722010

  • 25

    Rekate HL: Selecting patients for endoscopic third ventriculostomy. Neurosurg Clin N Am 15:39492004

  • 26

    Rotim KMiklic PPaladino JMelada AMarcikic MScap M: Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 13:5845871997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Simon TDButler JWhitlock KBBrowd SRHolubkov RKestle JR: Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 164:146214681468.e1–1468.e2 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Simon TDHall MRiva-Cambrin JAlbert JEJeffries HELafleur B: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:1561652009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Tulipan NCleves MA: Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 104 (1 Suppl):582006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Welch K: Residual shunt infection in a program aimed at its prevention. Z Kinderchir Grenzgeb 28:3743771979

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 1953 1953 97
Full Text Views 177 177 8
PDF Downloads 131 131 3
EPUB Downloads 0 0 0

PubMed

Google Scholar