Clinical and economic consequences of antibiotic-impregnated cerebrospinal fluid shunt catheters

Restricted access

Object

The authors evaluated the safety and efficacy of antibiotic-impregnated shunt catheters (AISCs) and determined the cost–benefit ratio related to the fact that AISCs increase the implant costs of a shunt procedure by ~ $400 per patient.

Methods

The control group comprised 98 adults with chronic hydrocephalus and 22 children, who were treated without AISCs (non-AISCs). In the treatment group, AISCs (Bactiseal, Codman, Johnson & Johnson) were implanted in 171 adults and 26 children. The minimum follow-up period was 6 months.

Results

Important risk factors for shunt infections (such as age, comorbidity, cause of hydrocephalus, operating time, and duration of external cerebrospinal fluid drainage prior to shunt placement) did not differ between the study and control groups. In the pediatric AISC group, the frequency of premature, shunt-treated infants and the incidence of external ventricular drainage prior to shunt insertion were actually higher than those in the non-AISC group. When using AISCs, the shunt infection rate dropped from 4 to 0.6% and from 13.6 to 3.8% in the adult and the pediatric cohort, respectively. Overall the infection rate decreased from 5.8 to 1%, which was statistically significant (p = 0.0145). The average costs of a single shunt infection were $17,300 and $13,000 in children and adults, respectively. The cost–benefit calculation assumed to have saved shunt infection–related costs of ~ $50,000 in 197 AISC–treated patients due to the reduction in shunt infection rate in this group compared with costs in the control group. Despite the incremental implant costs associated with the use of AISCs, the overall reduction in infection-related costs made the use of AISCs cost beneficial in the authors' department.

Conclusions

From clinical and economic perspectives, AISCs are seemingly a valuable addition in hydrocephalus therapy.

Abbreviations used in this paper: AISC = antibiotic-impregnated shunt catheter; CMI = Co-Morbidity Index; CSF = cerebrospinal fluid; EVD = external ventricular drainage; GAV = Gravity-Assisted Valve.

Article Information

Address correspondence to: Regina Eymann, M.D., Department of Neurosurgery, Saarland University Medical School, Kirrberger Street, Building 90, 66421 Homburg-Saar, Saarland, Germany. email: Regina.Eymann@uks.eu.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Ammirati MRaimondi A: Cerebrospinal fluid shunt infections in children. A study of the relationship between the etiology and hydrocephalus, age at the time of shunt placement, and infection rate. Childs Nerv Syst 3:1061091987

    • Search Google Scholar
    • Export Citation
  • 2

    Aryan HEMeltzer HSPark MSBennett RLJandial RLevy ML: Initial experience with antibiotic-impregnated silicone catheters for shunting of cerebrospinal fluid in children. Childs Nerv Syst 21:56612005

    • Search Google Scholar
    • Export Citation
  • 3

    Bayston RAshraf WBhundia C: Mode of action of an antimicrobial biomaterial for use in hydrocephalus shunts. J Antimicrob Chemother 53:7787822004

    • Search Google Scholar
    • Export Citation
  • 4

    Bayston RBhundia CAshraf W: Hydromer-coated catheters to prevent shunt infections?. J Neurosurg 102:2 Suppl2072122005

  • 5

    Bayston RGrove NSiegel JLawellin DBarsham S: Prevention of hydrocephalus shunt catheter colonisation in vitro by impregnation with antimicrobials. J Neurol Neurosurg Psychiatry 52:6056091989

    • Search Google Scholar
    • Export Citation
  • 6

    Bayston RLari J: A study of the sources of infection in colonised shunts. Dev Med Child Neurol 16:6 Suppl16221974

  • 7

    Bayston RMills AHowdle SMAshraf W: Comment on: the increasing use of silver-based products as antimicrobial agents: a useful development or a cause for concern?. J Antimicrob Chemother 60:4472007

    • Search Google Scholar
    • Export Citation
  • 8

    Boelens JJTan WFDankert JZaat SAJ: Antibacterial activity of antibiotic-soaked polyvinylpyrrolidone-grafted silicon elastomer hydrocephalus shunts. J Antimicrob Chemother 45:2212242000

    • Search Google Scholar
    • Export Citation
  • 9

    Borgbjerg BMGjerris FAlbeck MJBorgesen SE: Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir (Wien) 136:171995

    • Search Google Scholar
    • Export Citation
  • 10

    Boynton BRBoynton CAMerritt TAVaucher YEJames HEBejar RF: Ventriculoperitoneal shunts in low birth weight infants with intracranial hemorrhage: neurodevelopmental outcome. Neurosurgery 18:1411451986

    • Search Google Scholar
    • Export Citation
  • 11

    Chapman PHBorges LF: Shunt infections: prevention and treatment. Clin Neurosurg 32:6526641985

  • 12

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

  • 13

    Chopra I: The increasing use of silver-based products as antimicrobial agents: a useful development or a cause for concern?. J Antimicron Chemother 59:5875902007

    • Search Google Scholar
    • Export Citation
  • 14

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

  • 15

    Cochrane DDKestle JR: The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg 38:2953012003

    • Search Google Scholar
    • Export Citation
  • 16

    Cotton MFHartzenberg BDonald PRBurger PJ: Ventriculoperitoneal shunt infections in children. A 6-year study. S Afr Med J 79:1391421991

    • Search Google Scholar
    • Export Citation
  • 17

    Davis SELevy MLMcComb JGMasri-Lavine L: Does age or other factors influence the incidence of ventriculoperitoneal shunt infections?. Pediatr Neurosurg 30:2532571999

    • Search Google Scholar
    • Export Citation
  • 18

    Dennis MFitz CRNetley CTSugar JHarwood-Nash DCHendrick EB: The intelligence of hydrocephalic children. Arch Neurol 38:6076151981

    • Search Google Scholar
    • Export Citation
  • 19

    Drake JMKestle JRMilner RCinalli GBoop FPiatt J Jr: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:2943051998

    • Search Google Scholar
    • Export Citation
  • 20

    Ersahin YMutluer SGüzelbag E: Cerebrospinal fluid shunt infections. J Neurosurg Sci 1994:1611651994

  • 21

    Eymann RSteudel WIKiefer M: Pediatric gravitational shunts: initial results from a prospective study. J Neurosurg 106:3 Suppl1791842007

    • Search Google Scholar
    • Export Citation
  • 22

    Faillace WJ: A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Surg Neurol 43:3443501995

  • 23

    Fan-Havard PNahata MC: Treatment and prevention of infections of cerebrospinal fluid shunts. Clin Pharm 6:8668801987

  • 24

    Fernell Evon Wendt LSerlo WHeikkinen EAndersson H: Ventriculoatrial and ventriculoperitoneal shunts in the treatment of hydrocephalus in children?. Z Kinderchir 40:1 Suppl12141985

    • Search Google Scholar
    • Export Citation
  • 25

    Furno FMorley KSWong BSharp BLArnold PLHowdle SM: Silver nanoparticles and polymeric medical devices: a new approach to prevention of infections?. J Antimicrob Chemother 54:101910242004

    • Search Google Scholar
    • Export Citation
  • 26

    Gardner PLeipzig TPhillips P: Infections of central nervous system shunts. Med Clin North Am 69:2973141985

  • 27

    Gardner PLeipzig TJSadigh M: Infections of mechanical cerebrospinal fluid shunts. Curr Clin Top Infect Dis 9:1852141988

  • 28

    George RLeibrock LEpstein M: Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg 51:8048111979

    • Search Google Scholar
    • Export Citation
  • 29

    Govender STNathoo Nvan Dellen JR: Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg 99:8318392003

    • Search Google Scholar
    • Export Citation
  • 30

    Gray EDPeters GVerstegen MRegelmann WE: Effect of extracellular slime substance from Staphylococcus epidermis on the human cellular immune response. Lancet 1:3653671984

    • Search Google Scholar
    • Export Citation
  • 31

    Hampl JSchierholz JJansen BAschoff A: In vitro and in vivo efficacy of a rifampin-loaded silicone catheter for the prevention of CSF shunt infections. Acta Neurochir (Wien) 133:1471521995

    • Search Google Scholar
    • Export Citation
  • 32

    Hunt GMHolmes AE: Factors relating to intelligence in treated cases of spina bifida cystica. Am J Dis Child 130:8238271976

  • 33

    Jimenez DFKeating RGoodrich JT: Silicone allergy in ventriculoperitoneal shunts. Childs Nerv Syst 10:59631994

  • 34

    John SFHillier VFHandley PSDerrick MR: Adhesion of staphylococci to polyurethane and hydrogel-coated polyurethane catheters assayed by an improved radiolabeling technique. J Med Microbiol 43:1331401995

    • Search Google Scholar
    • Export Citation
  • 35

    Kan PKestle J: Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst 23:7737772007

    • Search Google Scholar
    • Export Citation
  • 36

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

  • 37

    Kariyattil RSteinbok PSinghal ACochrane DD: Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme. J Neurosurg 106:5 Suppl3503532007

    • Search Google Scholar
    • Export Citation
  • 38

    Kaufman BAManagement of complications of shunting. McLone DG: Pediatric Neurosurgery: Surgery of the Developing Nervous System ed 4PhiladelphiaSaunders2001. 529547

    • Search Google Scholar
    • Export Citation
  • 39

    Kestle JRCochrane DDDrake JM: Shunt insertion in the summer: is it safe?. J Neurosurg 105:3 Suppl1651682006

  • 40

    Kestle JRDrake JMCochrane DDMilner RWalker MLAbbott R III: Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg 98:2842902003

    • Search Google Scholar
    • Export Citation
  • 41

    Kestle JRGarton HJWhitehead WEDrake JMKulkarni AVCochrane DD: Management of shunt infections: a multi-center pilot study. J Neurosurg 105:3 Suppl1771812006

    • Search Google Scholar
    • Export Citation
  • 42

    Kestle JRHoffman HJSoloniuk DHumphreys RPDrake JMHendrick EB: A concerted effort to prevent shunt infections. Childs Nerv Syst 9:1631651993

    • Search Google Scholar
    • Export Citation
  • 43

    Kiefer MEymann RLeonhardt SWalter MMayer ANeumann K: Possibilities and limits of automatic detection of pathologic intracranial pressure waves with FFT. Biomed Tech 43:6131998

    • Search Google Scholar
    • Export Citation
  • 44

    Kiefer MEymann RMascarós VWalter MSteudel WI: [Significance of hydrostatic valves in the therapy of chronic hydrocephalus.]. Nervenarzt 71:9759862000. (Ger)

    • Search Google Scholar
    • Export Citation
  • 45

    Kiefer MEymann RSteudel WI: The dynamic infusion test in rats. Childs Nerv Syst 16:4514562000

  • 46

    Kiefer MEymann RSteudel WI: Outcome predictors for normal-pressure hydrocephalus. Acta Neurochir Suppl 963643672006

  • 47

    Kockro RAHampl JAJansen BPeters GScheihing MGiacomelli R: Use of scanning electron microscopy to investigate the prophylactic efficacy of rifampin-impregnated CSF shunt catheters. J Med Microbiol 49:4414502000

    • Search Google Scholar
    • Export Citation
  • 48

    Kohnen WSchäper JKlein OTieke BJansen B: A silicone ventricular catheter coated with a combination of rifampin and trimethoprim for the prevention of catheter-related infections. Zentralbl Bakteriol 287:1471561998

    • Search Google Scholar
    • Export Citation
  • 49

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

    • Search Google Scholar
    • Export Citation
  • 50

    Liptak GSMcDonald JV: Ventriculoperitoneal shunts in children: factors affecting shunt survival. Pediatr Neurosci 12:2892931985

  • 51

    Mancao MMiller CCochrane BHoff CSauter KWeber E: Cerebrospinal fluid shunt infections in infants and children in Mobile, Alabama. Acta Paediatr 87:6676701998

    • Search Google Scholar
    • Export Citation
  • 52

    O'Kane MCRichards HWinfield PPickard JD: The United Kingdom Shunt Registry. Eur J Pediatr Surg 7:1 Suppl561997. (Abstract)

  • 53

    Pattavilakom AKotasnas DKorman TMXenos CDanks A: Duration of in vivo antimicrobial activity of antibiotic-impregnated cerebrospinal fluid catheters. Neurosurgery 58:9309352006

    • Search Google Scholar
    • Export Citation
  • 54

    Pattavilakom AXenos CBradfield ODanks RA: Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J Clin Neurosci 14:5265312007

    • Search Google Scholar
    • Export Citation
  • 55

    Peters GLocci RPulverer G: Adherence and growth of coagulase-negative staphylococci on surfaces of intravenous catheters. J Infect Dis 146:4794821982

    • Search Google Scholar
    • Export Citation
  • 56

    Pople IKBayston RHayward WD: Infection of cerebrospinal fluid shunts in infants: a study of etiological factors. J Neurosurg 77:29361992

    • Search Google Scholar
    • Export Citation
  • 57

    Quigley MRReigel DHKortyna R: Cerebrospinal fluid shunt infections. Report of 41 cases and a critical review of the literature. Pediatr Neurosci 15:1111201989

    • Search Google Scholar
    • Export Citation
  • 58

    Rainov NSchobess AHeidecke VBurkert W: Abdominal CSF pseudocysts in patients with ventriculoperitoneal shunts. Report of fourteen cases and review of the literature. Acta Neurochir (Wien) 127:73781994

    • Search Google Scholar
    • Export Citation
  • 59

    Ratilal BCosta JSampaio C: Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 3:CD0053652006

    • Search Google Scholar
    • Export Citation
  • 60

    Renier DLacombe JPierre-Kahn ASainte-Rose CHirsch JF: Factors causing shunt infection: computer analysis of 1174 operations. J Neurosurg 61:107210781984

    • Search Google Scholar
    • Export Citation
  • 61

    Resch BMüller WOberbauer R: [Precipitating factors for shunt insufficiency in post-hemorrhagic hydrocephalus in the premature infant.]. Z Kinderchir 45:2032081990. (Ger)

    • Search Google Scholar
    • Export Citation
  • 62

    Ritz RRoser FMorgalla MDietz KTatagiba MWill BE: Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients. BMC Infect Dis 7:382007

    • Search Google Scholar
    • Export Citation
  • 63

    Schierholz JMPulverer G: Development of a new CSF-shunt with sustained release of an antimicrobial broad-spectrum combination. Zentralbl Bakteriol 286:107123

    • Search Google Scholar
    • Export Citation
  • 64

    Schiff SJOakes WJ: Delayed cerebrospinal-fluid shunt infection in children. Pediatr Neurosci 15:1311351989

  • 65

    Schoenbaum SCGardner PShillito J: Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J Infect Dis 131:5435521975

    • Search Google Scholar
    • Export Citation
  • 66

    Sciubba DMMcGirt MJWoodworth GFCarson BJallo GI: Prolonged exposure to antibiotic-impregnated shunt catheters does not increase incidence of late shunt infections. Childs Nerv Syst 23:8678712007

    • Search Google Scholar
    • Export Citation
  • 67

    Sciubba DMStuart RMMcGirt MJWoodworth GFSamdani ACarson B: Effect of antibiotic-impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J Neurosurg 103:2 Suppl1311362005

    • Search Google Scholar
    • Export Citation
  • 68

    Serlo WFernell EHeikkinen EAnderson Hvon Wendt L: Functions and complications of shunts in different etiologies of childhood hydrocephalus. Childs Nerv Syst 6:92941990

    • Search Google Scholar
    • Export Citation
  • 69

    Shanklin DRSmalley DL: Dynamics of wound healing after silicone device implantation. Exp Mol Pathol 67:26391999

  • 70

    Shurtleff DBFoltz ELLoeser JD: Hydrocephalus. A definition of its progression and relationship to intellectual function, diagnosis, and complications. Am J Dis Child 125:6886931973

    • Search Google Scholar
    • Export Citation
  • 71

    Shurtleff DBStuntz JTHayden PW: Experience with 1201 cerebrospinal fluid shunt procedures. Pediatr Neurosci 12:49571986

  • 72

    Vinchon MDefoort-Dhellemmes SNzeyimana CVallée LDhellemmes P: Infantile traumatic subdural hematomas: outcome after five years. Pediatr Neurosurg 39:1221282003

    • Search Google Scholar
    • Export Citation
  • 73

    Vinchon MDhellemmes P: Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:6926972006

  • 74

    Walter MKiefer MLeonhardt SSteudel WIIsermann R: Online analysis of intracranial pressure waves. Acta Neurochir Suppl 811611622002

    • Search Google Scholar
    • Export Citation
  • 75

    Walters BCGoumnerova LHoffman HJHendrick EBHumphreys RPLevinton C: A randomized controlled trial of perioperative rifampin/trimethoprim in cerebrospinal fluid shunt surgery. Childs Nerv Syst 8:2532571992

    • Search Google Scholar
    • Export Citation
  • 76

    Walters BCHoffman HJHendrick EBHumphreys RP: Cerebrospinal fluid shunt infections. J Neurosurg 60:101410211984

  • 77

    Zentner JGilsbach JFelder T: Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients. Neurosurg Rev 18:1691721995

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 178 177 15
Full Text Views 81 78 1
PDF Downloads 96 82 1
EPUB Downloads 0 0 0

PubMed

Google Scholar