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

Paul Klimo Jr. Semmes-Murphey Neurologic & Spine Institute;
Department of Neurosurgery, University of Tennessee Health Science Center; and
Le Bonheur Children’s Hospital, Memphis, Tennessee;

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Mark Van Poppel Department of Neurosurgery, University of Tennessee Health Science Center; and
Le Bonheur Children’s Hospital, Memphis, Tennessee;

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Clinton J. Thompson School of Public Health and Health Services, The George Washington University, Washington, DC;

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Lissa C. Baird Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon;

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Ann-Christine Duhaime Department of Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts; and

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Ann Marie Flannery Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

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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.

Abbreviations used in this paper:

AANS = American Association of Neurological Surgeons; CNS = Congress of Neurological Surgeons; RCT = randomized controlled trial; RR = risk ratio; VP = ventriculoperitoneal.
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