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Ann Marie Flannery, Catherine A. Mazzola, Paul Klimo Jr., Ann-Christine Duhaime, Lissa C. Baird, Mandeep S. Tamber, David D. Limbrick Jr., Dimitrios C. Nikas, Joanna Kemp, Alexander F. Post, Kurtis I. Auguste, Asim F. Choudhri, Laura S. Mitchell, and Debby Buffa

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David D. Limbrick Jr., Lissa C. Baird, Paul Klimo Jr., Jay Riva-Cambrin, and Ann Marie Flannery

Object

The objective of this systematic review was to examine the existing literature comparing CSF shunts and endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus and to make evidence-based recommendations regarding the selection of surgical technique for this condition.

Methods

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of CSF shunts and ETV for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been determined a priori were examined, and data were abstracted and compiled in evidentiary tables. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider treatment recommendations based on the evidence.

Results

Of the 122 articles identified using optimized search parameters, 52 were recalled for full-text review. One additional article, originally not retrieved in the search, was also reviewed. Fourteen articles met all study criteria and contained comparative data on CSF shunts and ETV. In total, 6 articles (1 Class II and 5 Class III) were accepted for inclusion in the evidentiary table; 8 articles were excluded for various reasons. The tabulated evidence supported the evaluation of CSF shunts versus ETV.

Conclusions

Cerebrospinal fluid shunts and ETV demonstrated equivalent outcomes in the clinical etiologies studied.

Recommendation: Both CSF shunts and ETV are options in the treatment of pediatric hydrocephalus. Strength of Recommendation: Level II, moderate clinical certainty.

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Lissa C. Baird, Catherine A. Mazzola, Kurtis I. Auguste, Paul Klimo Jr., and Ann Marie Flannery

Object

The objective of this systematic review was to examine the existing literature to compare differing shunt components used to treat hydrocephalus in children, find whether there is a superior shunt design for the treatment of pediatric hydrocephalus, and make evidence-based recommendations for the selection of shunt implants when placing shunts.

Methods

Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words chosen to identify publications comparing the use of shunt implant components. Abstracts of these publications were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was compiled summarizing the selected articles and quality of evidence. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider evidence-based treatment recommendations.

Results

Two hundred sixty-nine articles were identified using the search parameters, and 43 articles were recalled for full-text review. Of these, 22 papers met the study criteria for a comparison of shunt components and were included in the evidentiary table. The included studies consisted of 1 Class I study, 11 Class II studies, and 10 Class III studies. The remaining 21 articles were excluded.

Conclusions

An analysis of the evidence did not demonstrate a clear advantage for any specific shunt component, mechanism, or valve design over another.

Recommendation: There is insufficient evidence to demonstrate an advantage for one shunt hardware design over another in the treatment of pediatric hydrocephalus. Current designs described in the evidentiary tables are all treatment options. Strength of Recommendation: Level I, high degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend the use of a programmable valve versus a nonprogrammable valve. Programmable and nonprogrammable valves are both options for the treatment of pediatric hydrocephalus. Strength of Recommendation: Level II, moderate degree of clinical certainty.

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Paul Klimo Jr., Mark Van Poppel, Clinton J. Thompson, Lissa C. Baird, Ann-Christine Duhaime, and Ann Marie Flannery

Object

The objective of this systematic review and meta-analysis was twofold: to answer the question “What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?” and to make treatment recommendations based on the available evidence.

Methods

The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I2 statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

Results

Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38–0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not.

Conclusions

Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).

Recommendation

The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection. Strength of Recommendation: Level II, moderate degree of clinical certainty.

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Paul Klimo Jr., Clinton J. Thompson, Lissa C. Baird, and Ann Marie Flannery

Object

The objective of this systematic review and meta-analysis was to answer the following question: Are antibiotic-impregnated shunts (AISs) superior to standard shunts (SSs) at reducing the risk of shunt infection in pediatric patients with hydrocephalus?

Methods

Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to AIS use in children. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was assembled summarizing the studies and the quality of their evidence (Classes I–III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using the chi-square and I2 statistics. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

Results

Six studies, all Class III, met our inclusion criteria. All but one study focused on a retrospective cohort and all but one were conducted at a single institution. Four of the studies failed to demonstrate a lowered infection rate with the use of an AIS. However, when the data from individual studies were pooled together, the infection rate in the AIS group was 5.5% compared with 8.6% in the SS group. Using a random-effects model, the cumulative RR was 0.51 (95% CI 0.29–0.89, p < 0.001), indicating that a shunt infection was 1.96 times more likely in patients who received an SS.

Conclusions

We recommend AIS tubing because of the associated lower risk of shunt infection compared to the use of conventional silicone hardware (quality of evidence: Class III; strength of recommendation: Level III).

Recommendation: Antibiotic-impregnated shunt (AIS) tubing may be associated with a lower risk of shunt infection compared with conventional silicone hardware and thus is an option for children who require placement of a shunt. Strength of Recommendation: Level III, unclear degree of clinical certainty.