Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection

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Object

The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus?

Methods

The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I–III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I–III).

Results

A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).

Conclusions

Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.

Recommendation: Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Abbreviations used in this paper:EVD = external ventricular drain; VA = ventriculoatrial; VP = ventriculoperitoneal.

Object

The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus?

Methods

The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I–III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I–III).

Results

A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).

Conclusions

Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.

Recommendation: Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Cerebrospinal fluid shunt infection is one of the most common and serious complications of CSF shunt therapy. Infection admissions number approximately 2300 per year in the United States and, in aggregate, account for more than 50,000 hospital days.29 Total hospital charges related to the management of CSF shunt infection were nearly $250 million in 2003 adjusted dollars.29

Within 24 months after insertion, infections complicate approximately 11% of initial CSF shunt placements.28 Despite the high incidence of this complication, the optimal management of CSF shunt infection has yet to be defined. The existing evidence regarding the management of CSF shunt infection is of poor methodological quality. As such, current management is dictated not by evidence, but rather by physician preference and other possibly relevant patient-level factors (for example, patient surgical risk, ventricle size, and complexity of the shunt system). It is not surprising that there is significant variation in CSF shunt infection treatment protocols between centers.35

The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus? The successful treatment of CSF shunt infection aims to cure the infection (that is, minimize the probability of reinfection or relapse) while maintaining functional CSF diversion and minimizing morbidity, mortality, and the cost of therapy. The alternative paradigms for the management of ventricular shunt infection are illustrated well if one considers important historical milestones in the treatment of hydrocephalus. The evidentiary tables are structured somewhat accordingly (Fig. 1). The development of the Holter-Pudenz valve in 1957 and the ability to insert the distal end of a ventricular shunt into the right atrium was a major development in the treatment of hydrocephalus. Although ventriculoatrial (VA) shunts facilitated continuous and regulated CSF diversion, the fact that the distal catheter entered the heart posed logistical problems when these shunts inevitably became infected. A major issue with VA shunts was loss of limited venous access if these shunts were removed and not immediately replaced. In light of this limitation, the predominance of literature examining the treatment of CSF shunt infections in the era of VA shunts documented the outcomes of treatment with systemic antibiotics alone (Table 1) and whether the elevated CSF antibiotic concentrations achieved by intrathecal therapy conferred any additional benefit in managing the ventriculitis that often accompanied CSF shunt infection—both while leaving the infected shunt in situ or after removing the shunt and immediately replacing it in infected cerebrospinal fluid (Table 2).

Fig. 1.
Fig. 1.

Organization of evidentiary tables based on alternative paradigms for the management of CSF shunt infection.

TABLE 1:

Systemic antibiotic treatment with shunt left in situ or removed and immediately replaced: summary of evidence*

Authors & YearStudy DescriptionData Class, Quality, & ReasonsResults & Conclusions
Forrest et al., 198712 VA shunt infections w/ positive blood cultures (but sterile CSF) treated w/ IV antibiotics & complete shunt removal w/ immediate shunt replacement.Class III12 of 12 pts w/ positive blood cultures but sterile CSF were w/o evidence of recolonization at last follow-up.
Retrospective case series.
11 other pts w/ positive blood & CSF cultures were treated w/ IV antibiotics, shunt removal, & EVD w/ delayed shunt replacement, but treatment outcomes are not presented.
Outcome: no evidence of recolonization at last follow-up (3–16 yrs).Difficult to interpret findings in isolation.
Odio et al., 198459 shunt infections managed w/ systemic antibiotics alone (Group A, n = 13); systemic antibiotics + immediate shunt removal (Group B, n = 37); or systemic antibiotics + delayed shunt removal (Group C, n = 9).Class IIICure in 8 of 13 pts treated w/ antibiotics alone, 34 of 37 pts treated w/ antibiotics + immediate shunt removal, & 8 of 9 pts w/ antibiotics + delayed shunt removal.
Retrospective case series.
Poor control of confounders.
Reasons for immediate vs delayed shunt removal not given (selection bias).
Outcome: cure (absence of shunt reinfection or relapse).Results suggest a poorer outcome w/o shunt removal.
Timing of outcome assessment not given.
Walters et al., 1984267 infections treated in 222 pts. 92 treated medically (85 systemic, 7 systemic + IT antibiotics); 117 treated medically + surgically (21 pts: the shunt was removed & immediately replaced under antibiotic coverage; 51 pts: shunt removal + antibiotics + delayed shunt replacement; 20 pts: shunt removal + EVD/shunt externalization + IT antibiotics; 25 pts: shunt removal + antibiotics w/o shunt replacement); 58 pts: no specific treatment of shunt infection (e.g., unrecognized shunt infection).Class III37% mortality w/ medical management alone.
Retrospective case series.18% mortality w/ medical + surgical therapy; lowest mortality in those in whom shunt was removed & replaced under antibiotic coverage in a single operation.
Definition of cure (another tabulated outcome) not provided.
Multiple different permutations & combinations of treatment w/o clear criteria matching a particular patient w/ a particular treatment (selection bias).
Addition of surgical therapy appears to lower morbidity & mortality of shunt infection.
Nontraditional outcome.
Outcome: death.
Schoenbaum et al., 197598 shunt infections among 442 shunt procedures in 289 pts. Initial treatment based on shunt type. VP shunts were all completely removed & treated w/ IV antibiotics; some pts w/ VA & V-ureteral shunts were initially managed w/ IV antibiotics alone.Class III1 of 30 pts treated w/ complete shunt removal & IV antibiotics died; 28 of 30 pts obtained control of infection.
Retrospective case series.
Poor control of confounders.
Selection bias.6 of 43 pts w/ VA & V-ureteral shunts treated w/ IV antibiotics alone died; 13 of 43 pts obtained control of infection.
Outcome: death.Authors cite “control of infection” as outcome, but not clearly defined.
Nontraditional outcome.Shunt removal is required for improved outcome.
Shurtleff et al., 197467 pts w/ shunt infection treated w/ IV antibiotics alone (Group A, n = 22); IV antibiotics + shunt revision (Group B, n = 14); IV antibiotics + complete shunt removal & replacement (Group C, n = 12); IV + IT antibiotics + complete shunt removal & replacement (Group D, n = 7); IV + IT/intrashunt antibiotics alone (Group E, n = 10); or IV + IT antibiotics w/ shunt revision (Group F, n = 2).Class IIICure in 2 of 22 pts (Group A), 3 of 14 pts (Group B), 12 of 12 pts (Group C), 7 of 7 pts (Group D), 3 of 10 pts (Group E), & 0 of 2 pts (Group F).
Retrospective case series.
No control of confounders.
Rationale for selecting different therapies for different infections not clear (“therapy evolved during the study”) (selection bias).Highest cure rate in pts w/ complete shunt removal & replacement, irrespective of whether they received supplemental IT antibiotics.
Outcome: cure (no symptoms & at least 6 negative blood cultures & 2 negative ventricular/shunt CSF cultures during a 6-mo period after cessation of antibiotics).
Morrice & Young, 1974Pts w/ colonization of VA shunt valves treated w/ antibiotics alone (n = 14); removal & immediate replacement of shunt (n = 23); or removal of shunt w/ a period of external drainage, followed by delayed shunt insertion (n = 18).Class III2 of 14 pts treated w/ antibiotics alone are alive & well at 6 mos.
Retrospective case series.
Poor control of confounders.11 of 23 pts treated w/ removal & immediate replacement of shunt are alive & well at 6 mos.
Selection bias.
Outcome = “alive & well” at 6 mos.Route of administration of antibiotics not specified.8 of 18 pts treated w/ removal of shunt w/ a period of external drainage, followed by delayed shunt insertion are alive & well at 6 mos.
Unclear if pts who underwent surgical treatment (immediate or delayed shunt replacement) received supplemental antibiotics.
Results suggest that shunt removal is required to optimize outcome.
No specific microbiological component of outcome.
Nicholas et al., 197060 infections of VA shunts treated w/ IV antibiotics (also IT antibiotics if the CSF was infected) & delayed shunt replacement (n = 33 infections) or w/ IV antibiotics & immediate shunt replacement (n = 27 infections).Class IIISuccessful treatment in 24 of 33 infections treated w/ IV antibiotics (also IT antibiotics if the CSF was infected) & delayed shunt replacement vs 21 of 27 infections treated w/ IV antibiotics & immediate shunt replacement.
Retrospective case series.
No control of confounders.
Selection bias.
Outcome: “Subsequent good health of the patient & freedom from bacteremia.”Nondescript outcome.
Recurrence/relapse higher in pts w/ immediate shunt replacement.

IT = intrathecal; IV = intravenous; pts = patients; V-ureteral = ventriculoureteral.

TABLE 2:

Systemic and intrathecal antibiotic treatment with shunt left in situ or removed and immediately replaced: summary of evidence*

Authors & YearStudy DescriptionData Class, Quality, & ReasonsResults & Conclusions
James et al., 198150 pts (30 reported in James et al., 1980 RCT) w/ shunt infection treated w/ shunt removal, systemic antibiotics, & either EVD or ventricular taps for decompression & antibiotic administration (Group A, n = 22); removal & immediate replacement of shunt w/ intrashunt & systemic antibiotics (Group B, n = 17); or intrashunt & systemic antibiotics w/o shunt removal (Group C, n = 11).Class II21 of 22 pts in Group A were successfully treated.
Prospective nonrandomized cohort.15 of 17 pts in Group B were successfully treated.
4 of 11 pts in Group C were successfully treated.
Continuation of James et al., 1980 RCT—high incidence of failures in medical management arm (i.e., no shunt removal) made further randomization unjustified.Suggests better treatment outcomes w/ shunt removal.
Suggests that IT antibiotics may be of use if shunt must be removed & immediately replaced rather than replaced in a delayed fashion (when infection has been cleared).
Outcome: negative ventricular CSF cultures 48 hrs after cessation of antibiotic therapy & again w/in 4 mos of completion of therapy.
James et al., 198030 pts w/ shunt infection treated w/ shunt removal, systemic antibiotics, & either EVD or ventricular taps for decompression & antibiotic administration (Group A, n = 10); removal & immediate replacement of shunt w/ intrashunt & systemic antibiotics (Group B, n = 10); or intrashunt & systemic antibiotics w/o shunt removal (Group C, n = 10).Class II10 of 10 pts in Group A were successfully treated.
RCT w/ design flaws.9 of 10 pts in Group B were successfully treated.
Suboptimal randomization & allocation.3 of 10 pts in Group C were successfully treated.
Length of hospital stay lowest in Group A.
Baseline characteristics of treatment groups not documented.Deaths only occurred in Group C.
Suggests better treatment outcomes w/ shunt removal.
Outcome: negative ventricular CSF cultures 48 hrs after cessation of antibiotic therapy & again w/in 4 mos of completion of therapy.Unclear if outcome assessment was blinded.Suggests that IT antibiotics may be of use if shunt must be removed & immediately replaced rather than replaced in a delayed fashion (when infection has been cleared).
Underpowered (but study terminated early for harm).
Bayston & Rickwood, 198143 children w/ staphylococcal VA or VP shunt infection treated w/ antibiotics alone (systemic or systemic + IT).Class IIIEradication of infection in 5 of 43 pts.
Retrospective case series.4 of 5 of those pts w/ eradication of infection received IT antibiotics.
Outcome: eradication of infection (response during treatment w/ no clinical relapse, followed by repeated normal serological & bacteriological studies).Timing of outcome assessment not clear.No eradication of Staphylococcus aureus shunt infection.
Suggests the utility of supplemental IT antibiotics if the shunt cannot be removed.
Wald & McLaurin, 198020 pts w/ shunt infection treated w/ daily IT antibiotics (w/ systemic antibiotics) w/o removal of the shunt or EVD placement.Class III“Cure” in 5 of 7 pts receiving at least 7 days of IT methicillin.
Retrospective case series.“Cure” in 4 of 5 pts treated w/ IT gentamicin.
Outcome: cure (2 or 3 sterile CSF cultures 72 hrs after completion of antibiotics).Pharmacodynamic study.“Cure” in 6 of 7 pts receiving a single 2-wk course of IT cephalothin.
Rates of “cure” appear higher than medically treated pts receiving systemic antibiotics alone.
Sells et al., 197720 gram-negative shunt infections receiving 25 total treatment trials. Treatments were none (n = 2); systemic antibiotics alone (n = 4); systemic & intraventricular antibiotics alone (n = 4); systemic antibiotics plus in situ shunt replacement (i.e., into the infected tract or incomplete shunt replacement (n = 2); systemic & intraventricular antibiotics w/ in situ shunt replacement (i.e., into the infected tract) or incomplete shunt replacement (n = 4); systemic & intraventricular antibiotics w/ complete shunt removal or replacement in a new site (n = 9).Class IIICure in 0 of 2 pts receiving no treatment.
Retrospective case series.Cure in 1 of 4 pts receiving systemic antibiotics alone.
Poor control of confounders.Cure in 0 of 4 pts receiving systemic & intraventricular antibiotics alone.
Selection bias.Cure in 1 of 2 pts receiving systemic antibiotics plus in situ shunt replacement or incomplete shunt replacement.
Very few pts receiving each individual treatment.
Cure in 0 of 4 pts receiving systemic & intraventricular antibiotics w/ in situ shunt replacement or incomplete shunt replacement.
Cure in 9 of 9 pts receiving systemic & intraventricular antibiotics w/ complete shunt removal or replacement in a new site.
Outcome: cure (asymptomatic patient w/ at least 6 negative blood cultures & 2 negative ventricular or shunt CSF cultures obtained during a 6-mo period after cessation of antibiotics).Clear advantage of complete vs incomplete shunt removal. No clear additional advantage of IT antibiotics in pts treated medically or medically w/ in situ shunt replacement or incomplete shunt replacement.
McLaurin,197525 shunt infections (23 VA & 2 VP) treated w/ IV + IT antibiotics & delayed shunt replacement (n = 4), IV + IT antibiotics w/ immediate shunt replacement (n = 10), or IV + IT antibiotics alone (n =11).Class IIIAbsence of residual infection at last follow-up in all 24 surviving pts (infection believed to have been cured in the 1 patient who died).
Retrospective case series.
Characteristics of those pts successfully treated w/ IV + IT antibiotics alone (i.e., w/o shunt removal & replacement) not documented (selection bias).Suggests that IT antibiotics may be of use if shunt is not removed or must be removed & immediately replaced.
Outcome: absence of residual infection at last follow-up (6 mos–5 yr).Extension of McLaurin, 1975 series.Shunt removal may not be necessary for successful treatment of shunt 0infection if IT antibiotics are administered.

RCT = randomized controlled trial.

A decade later, Ames developed a technique for placement of the distal catheter in the peritoneal space, and as such, made shunt removal and later replacement a feasible surgical strategy in the management of CSF shunt infection. Over time, the combined medical and surgical treatment of ventricular shunt infection became more accepted, in part because of the gradual phase-out of VA shunts and their associated limitations with respect to repeated surgical access to the heart, but perhaps more significantly because of the realization that an infected ventricular shunt, as an infected foreign body, was difficult if not impossible to sterilize using antibiotics alone. This management philosophy accepts not only that shunt removal (and eventual replacement once CSF sterility is achieved) requires multiple surgeries, but also the risk of introducing secondary infection during a variable period of external drainage. Therefore, although more contemporary literature examining the treatment of CSF shunt infection consists of studies that incorporate some form of shunt removal, variations in whether the infected shunt was partially removed (that is, externalized) (Table 3) or completely removed (see Table 4), and whether supplemental intrathecal antibiotics were administered contribute to significant between-study heterogeneity.

TABLE 3:

Partial shunt removal and treatment with systemic antibiotics or with systemic and intrathecal antibiotics: summary of evidence

Authors & YearStudy DescriptionData Class, Quality, & ReasonsResults & Conclusions
James & Bradley, 200810Prospective nonrandomized study of 2 protocols for treating complicated shunt infections (multiloculated, multiorganism, infection at other site in body).Class IIIAll pts treated according to either protocol were cured.
Nonrandomized, prospective case series.
Length of stay protocol in Group A = 25.1 days vs protocol in Group B = 19.7 days.
Outcome is different for each treatment group.
Group A, n = 21 treated w/ IV (2 wks) & IT antibiotics injected through EVD (n = 10) or reservoir of externalized shunt (n = 11) (2×/wk for 2 wks). 3 wks of antibiotics in total. Outcome: cure (cultures 48 hrs after cessation of antibiotics, at time of new shunt placement, & 3–6 mos later remained negative).No recurrent shunt infections during the follow-up period.
Pts w/ complicated shunt infections can be successfully treated w/ 2 wks of once daily IT therapy concurrent w/ 3 wks of IV therapy (& EVD or shunt externalization).
Group B, n = 18 treated w/ IV (2 wks) & IT antibiotics injected through EVD or reservoir of externalized shunt (1×/wk for 2 wks). 3 wks of antibiotics in total. Outcome: cure (cultures 24 hrs after cessation of antibiotics, at time of new shunt placement, & 3–6 mos later remained negative).
Arnell et al., 2007Retrospective review of 34 consecutively treated intraventricular shunt infections treated w/ externalization of the ventricular catheter proximal to the valve, daily IT injections (generally guided by CSF antibiotic concentrations, median 8 days), & IV antibiotics (median 10 days). Usually no antibiotics after shunt replacement.Class IIICSF sterilized in 1 of 3, 7 of 8, 20 of 20, & 6 of 6 cases after 1, 2, 3, & >3 days of therapy (externalization of ventricular catheter & start of IT antibiotics). Clinical symptoms resolved in parallel w/ the sterilization of CSF.
Retrospective case series.
No control of confounders.
Despite the ventricular catheter being left in place & the short duration of therapy, the treatment protocol results in quick CSF sterilization, a low relapse rate, & survival of all pts in this series.
Outcome: cure (sterilization of CSF & resolution of clinical symptoms).
Wang et al., 199923 pts treated according to a documented management protocol (externalization of distal catheter unless failure to sterilize CSF, empiric followed by tailored antibiotics for 10 days following sterilization of CSF, reimplantation of shunt if cultures remain negative for 3 days off antibiotics). Comparison group of 10 historical controls treated w/ an undisclosed regimen.Class IIIReinfection 0 of 15 pts treated under protocol (8 pts did not require shunt reinsertion) vs 2 of 10 treated before protocol.
Comparative study w/ historical controls.
No control of confounders.Shorter hospital stay in those treated under the protocol.
3 pts had a ventricular reservoir only.
Of those treated under the protocol, pts w/ a “complex” shunt system required longer hospitalization.
Details of treatment of historical control pts not clear (“duration of antibiotic therapy for each individual case was decided arbitrarily”).
Outcome: recurrence (reinfection w/ same organism w/in 6 mos).This treatment protocol may be effective in the management of shunt infection.
Ronan et al., 199541 episodes of infection in 39 children treated w/ antibiotics (28 IV & oral, 11 IV + IT + oral, 4 IT + IV, 1 IT + oral) & surgical treatment (complete or partial shunt removal & immediate or delayed replacement w/ or w/o external ventricular drainage).Class IIIAbsence of relapse in 31 pts, relapse in 6 pts, death in 4 pts (not directly related to shunt infection).
Retrospective case series.
Selection bias.Outcome not dependent on length of antibiotic treatment or use of IT antibiotics.
Outcome: absence of relapse (reinfection w/ same organism) at 3 mos, & was verified by the absence of relapse for the follow-up period (min 1 year).Overall management approach too varied to allow for reasonable conclusions to be made.Surgical approach to treatment too varied to permit conclusions about efficacy. Complete shunt replacement associated w/ lower risk of relapse vs partial replacement, & delayed replacement had better outcomes vs immediate replacement.
TABLE 4:

Complete shunt removal and treatment with systemic or systemic and intrathecal antibiotics: summary of evidence

Authors & YearStudy DescriptionData Class, Quality, & ReasonsResults & Conclusions
Kestle et al.,200670 pts from 10 centers followed prospectively for 1 yr following successful treatment of shunt infection. Initial management was shunt externalization & antibiotics in 17 pts; shunt removal, EVD insertion,& antibiotics in 50 pts; & antibiotic treatment alone in 3 pts.Class IIReinfection occurred in 18 pts (26%); in 12 pts due to the same initial organism & in 6 pts due to different organisms.
Prospective multicenter observational study.
Reinfection rates in those externalized vs completely removed not provided separately.
Reinfection risk was not associated w/ length of antibiotic treatment.
Outcome: culture-proven reinfection (same or different organism).Timing of outcome assessment not clear.
This study reconfirms the high reinfection rate in pts receiving treatment for shunt infection.
Shimuzu et al.,2012Retrospective chart review of 36 pts w/ shunt removal, EVD placement (in 4 pts there was externalization prior to EVD placement), IV antibiotics, & eventual shunt replacement, compared to 9 pts w/ shunt removal, IV antibiotics, & ETV for treatment of shunt infection.Class IIIOf those treated w/ shunt removal followed by reinsertion, 10 of 36 experienced CSF reinfection.
Retrospective case series.
No control of confounders.This study reconfirms the high reinfection rate in pts receiving treatment for shunt infection.
Selection bias.
Outcome: recurrence of CSF infection w/in 6 mos after shunt reinsertion or ETV.
James & Bradley, 20089Retrospective nonrandomized comparison of 2 protocols for treating uncomplicated shunt infections (single shunt system, single organism, noncompartmentalized hydrocephalus).Class IIIAll pts treated according to either protocol were cured.
Retrospective comparative study.
Outcome is different for each treatment group.Duration of IV antibiotics: Protocol A = 9.7 days vs Protocol B = 9.9 days.
Group A, n = 25 w/ shunt removal/EVD, IV antibiotics until clinical course & CSF values suggested cure of infection, IT antibiotics 2×/wk through EVD or at times of ventricular puncture.
Pts w/ a single shunt infected w/ a single organism & w/ noncompartmentalized hydrocephalus may be successfully treated w/o a prolonged antibiotic course & lengthy hospital stay, provided the shunt is completely removed.
Outcome: cure (cultures 48 hrs after cessation of antibiotics, at time of new shunt placement, & 3–6 mos later remained negative).
Group B, n = 15 w/ shunt removal/EVD, IV antibiotics until clinical course & CSF values suggested cure of infection, IT antibiotics 1×/wk through EVD or at times of ventricular puncture.
Outcome: cure (cultures 24 hrs after cessation of antibiotics, at time of new shunt placement, & 3–6 mos later remained negative).
Schuhmann et al., 200535 consecutive culture-proven shunt infections were treated w/ antibiotics, surgery for shunt removal/EVD placement, or shunt externalization & eventual reinternalization of the shunt.Class III6 of 33 pts experienced a shunt reinfection.
Prospective case series.This study reconfirms the high reinfection rate in pts receiving treatment for shunt infection.
Details of management of shunt infection not clear (e.g., no. of pts who underwent complete vs incomplete shunt removal & no. of pts who had intrathecal supplementation to systemic antibiotic therapy, if any).
Outcome: shunt reinfection.
Outcomes not provided separately for shunts externalized vs shunts completely removed.
Turgut et al., 200537 infections in 35 pts. 31 pts treated w/ shunt removal, EVD, & systemic + IT antibiotics. 4 pts treated w/ medical management alone.Class III2 of 31 pts treated w/ shunt removal, EVD, & systemic + IT antibiotics died.
Retrospective case series.
Outcome: death.Nontraditional outcome.1 of 4 pts treated medically died.
Criteria for treating 4 pts medically not clear (selection bias).Good outcomes w/ IT therapy, but no pts underwent shunt removal w/ systemic antibiotics alone.
Mancao et al., 199829 consecutive shunt infections treated. 27 pts had shunt removal ± external drainage. All received IV antibiotics, & 6 pts received supplemental IT antibiotics.Class III27 pts had successful treatment (no relapse). 2 deaths not clearly related to shunt infection.
Retrospective case series.
Definition of outcome (relapse) not provided; follow-up period was not defined.This study demonstrates a lower rate of reinfection than other studies, but the data are of poor quality.
Outcome: relapse of infection.
Criteria for IT antibiotics not given.
Stamos et al., 199323 consecutive gram-negative shunt infections, managed w/ complete shunt removal, EVD, & IV antibiotics (n = 19) or IT antibiotics (n = 2) for persistent positive cultures.Class IIIAll pts obtained cure w/ shunt removal, EVD placement, & antibiotics (19 IV, 2 IV + IT).
Retrospective case series.
No control of confounders.On late follow-up of 19 pts (>6 mos), 4 had subsequent coagulase-negative staphylococcal infection.
Outcome: “cure” (asymptomatic & at least 3 negative cultures after cessation of antibiotics), after which shunt was reinserted.
Despite initial success, reinfection rates appear similarly high when compared w/ other studies.
Kontny et al., 199328 infections in 25 pts, treated w/ IV antibiotics & immediate removal of the shunt system (n = 24) or IV antibiotics alone (n = 4).Class IIIAll pts were w/o reinfection or relapse.
Retrospective case series.Short follow-up precludes definitive conclusions.
Outcome: reinfection or relapse w/in 1 mo of completion of therapy.Details of management of infection not given.
Short follow-up.
James et al., 198418 infections (13 following initial shunt procedure & 5 following revisions) in low-birth-weight infants (<2000 g) treated promptly w/ shunt removal & IV + IT antibiotics (see James et al., 1980).Class IIIAll except 1 patient demonstrated cure when treated according to protocol.
Retrospective case series.
Outcome not clearly defined (although, if per James 1980, then as follows: Negative cultures 48 hrs after cessation of antibiotics & w/in 4 mos of completion of therapy).Good outcomes w/ IT therapy, but no pts underwent shunt removal w/ systemic antibiotics alone.
Outcome: cure.
Scarff et al., 197857 children w/ shunt-related ventricular infection treated w/ IV + IT antibiotics & external ventricular drainage (either shunt removal & EVD, or shunt externalization).Class III54 of 57 pts demonstrated clearance of infection.
Retrospective case series.Good outcomes w/ IT therapy, but no pts underwent shunt removal w/ systemic antibiotics alone.
No. of pts receiving each surgical therapy (shunt removal & EVD, or shunt externalization) were not documented, nor were their outcomes differentially reported.
Outcome: clearance of infection (3 consecutive cultures w/ negative growth at 48 hrs).

A lack of rigorous comparative effectiveness studies leads to uncertainty regarding the preferred therapeutic strategy for a particular clinical circumstance. Decision analytical modeling attempts to apply statistical simulation techniques to preexisting data to rank competing therapeutic options in terms of their relative effectiveness. A decision analysis examining the treatment of CSF shunt infection using data from published studies (most included in evidentiary Tables 14) came to the conclusion that the best treatment modality for CSF shunt infection was antibiotic administration (systemic, with or without intrathecal administration) and complete removal of the infected shunt, with intercurrent external ventricular drainage or ventricular taps, followed by placement of a new shunt when CSF sterility is achieved. Sensitivity analyses revealed that this treatment option had the highest cure rate, the lowest failure rate, and the lowest mortality rate when compared with treatment consisting of antibiotic therapy with shunt removal and immediate replacement, or antibiotic treatment alone, over a wide range of assumptions.23

Multiple review articles on the topic also conclude that shunt infection should be ideally managed with antibiotics, complete shunt removal, and placement of a temporary external ventricular drain (EVD), followed by reimplantation after CSF sterilization.1,4,7,36,37 Although intrathecal administration of antibiotics appears to make theoretical sense because of enhanced CSF antibiotic concentrations, its practical application is controversial, owing in large part to the potential adverse effects of intrathecal therapy, including neurotoxicity. The indications for intrathecal therapy are not well established and presently range from use in any shunt infection, use in only those infections in which the CSF cannot be sterilized by systemic antibiotics alone (for example, persistent positive cultures), or use in those ventricular shunt infections caused by specific organisms (for example, gramnegative infections).

A practice survey of board-certified members of the American Society of Pediatric Neurosurgeons revealed that most surgeons treat ventricular shunt infection with antibiotics, removal of the infected CSF shunt, and placement of an EVD, followed by delayed shunt replacement— a management paradigm that can be supported by the available evidence, as detailed below.35

Methods

Search Criteria

We searched the US National Library of Medicine (PubMed/MEDLINE) database and the Cochrane Database of Systematic Reviews for the period January 1966 through March 2012 using the following MeSH subject headings: (CSF shunts) AND (bacterial infection OR prosthesis-related infection OR catheter-related infection) AND (treatment OR outcome) AND (antibacterial agents OR injections OR antibiotics OR device removal OR ventriculostomy OR combined modality therapy). Searches were limited to studies in patients younger than 18 years of age, the management of initial (not repeat) CSF shunt infection, and to the English language.

Search Results

A total of 342 abstracts were screened and 69 fulltext articles were retrieved for review. The details of this process are described in Part 1, the introduction and methodology section of these guidelines.5 An examination of the reference lists of these 69 full-text articles yielded an additional 24 articles that warranted full-text review (Fig. 2). Subsequent review of the full texts of these 93 articles led to the exclusion of 66 articles based on predefined criteria, leaving 27 articles as the basis for the evidentiary tables for this particular recommendation. Reasons for exclusion of full-text articles included the following: literature review (n = 19); no treatment outcomes given (n = 14); pediatric patients not reported separately (n = 6); wrong target population (n = 1); small sample size (n = 19); not a full report of a clinical study (n = 2); not relevant to the study question (n = 3); and other (n = 2).

Fig. 2.
Fig. 2.

Flowchart showing the process involved in identifying relevant literature.

Results

In general, the methodological quality of the evidence related to this recommendation was poor. The studies that met our inclusion criteria were typically descriptive series of small numbers of patients and were vulnerable to the biases and limitations of a retrospective study design. Because the studies relied on the accuracy and completeness of the medical record, the control of potentially confounding variables was nonexistent. Although most studies did compare outcomes between patient groups treated under alternative management protocols, the rationale behind why a particular treatment was assigned to a particular patient group was not clearly described, leading to significant issues with selection bias. For those studies describing the outcomes of a single management protocol, between-study comparisons of results was hampered by widely disparate management protocols and the use of nonuniform outcome measures (and definitions thereof). These limitations precluded, for the most part, any meaningful quantitative synthesis of the data; what follows is a largely qualitative review of the evidence relevant to this recommendation.

Despite the overall predominance of Class III data, the 13 studies presented in evidentiary Tables 16,17–19,22,27,33 and 23,11,12,16,25,32 are quite suggestive of the notion that in the management of CSF shunt infection, supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal should be considered. Two Class II studies provide particularly compelling evidence in favor of a combined medical and surgical management of CSF shunt infection, and deserve to be elaborated on further.

In 1980, James et al.12 published the results of a moderate-quality randomized controlled trial in which 10 patients with evidence of CSF shunt infection were randomized to each of 3 different treatment arms: 1) complete shunt removal, systemic antibiotics, and either external ventricular drainage or ventricular taps for decompression and intrathecal antibiotic administration, with delayed shunt replacement; 2) complete shunt removal and immediate shunt replacement with intrashunt and systemic antibiotics; or 3) intrashunt and systemic antibiotics without shunt removal. The outcome was negative ventricular CSF cultures 48 hours after cessation of antibiotic therapy and again within 4 months of completion of therapy. All 10 patients who underwent complete shunt removal, systemic antibiotics, and either external ventricular drainage or ventricular taps for decompression and intrathecal antibiotic administration were successfully treated. Nine of 10 patients treated with complete shunt removal and immediate shunt replacement with intrashunt and systemic antibiotics achieved therapeutic success. In contrast, only 3 of 10 patients who received systemic and intrathecal antibiotics without shunt removal were successfully treated. The treatment results in this latter group rather clearly demonstrate that shunt removal, rather than antibiotic therapy (including intrathecal therapy), was responsible for the improved outcomes seen in the comparison groups. Secondary outcomes also were consistent with a benefit toward surgical removal of the shunt, as length of hospital stay was lowest in those patients who underwent complete shunt removal with delayed shunt replacement after a course of systemic and intrathecal antibiotics. The only deaths occurred in those patients who received medical management alone. Because of the convincing inferiority of medical management alone, further randomization to this group was halted, but the study was continued as a prospective nonrandomized comparison of treatment outcomes between those patients receiving intrathecal and systemic antibiotics in conjunction with complete shunt removal and delayed versus immediate shunt replacement.11 The principal conclusions remain unchanged.

The nearly equivalent treatment outcomes of shunt removal followed by immediate shunt replacement (that is, shunt replacement in infected CSF) versus delayed shunt replacement (that is, shunt replacement after the CSF has been sterilized) in the aforementioned studies by James and colleagues11,12 was suggestive of the potential utility of intrathecal antibiotics in those clinical circumstances in which the shunt must be removed and immediately replaced. As such, these studies provide some evidence applicable to the intrathecal antibiotic recommendation as well. As outlined earlier, it appears that most of the treatment effect comes from shunt removal, making the relative contribution of intrathecal antibiotics to improved outcomes in this scenario rather uncertain. Hence, elevating the recommendation for intrathecal antibiotics to a Level II recommendation, based on these relatively high quality data alone, appears unwarranted.

Additional evidence pertaining to the intrathecal antibiotic recommendation comes largely from Class III studies that examined the results of treatment of ventricular shunt infection in those clinical circumstances in which the infected shunt components are not removed (Table 23,11,12,16,25,32) or only partially removed (that is, externalized) (Table 32,10,20,34). There was a Class III study that documented a fairly large proportion of patients who achieved therapeutic success—comparable to the success seen in patients who underwent shunt removal—when the patients were treated with intrathecal antibiotics but their shunts were left in situ.16 In addition, Bayston and Rickwood3 documented eradication of staphylococcal VA or VP shunt infection in 5 of 43 patients who underwent antibiotic treatment alone; 4 of the 5 patients who were successfully treated received intrathecal antibiotics. In cases in which ventricular shunt infection was treated with systemic and intrathecal antibiotics along with shunt externalization, either because of the complexity of the shunt infection scenario (for example, multiloculated hydrocephalus) or surgeon preference, a prospective nonrandomized study by James and Bradley10 and a Class III study by Arnell et al.2 were both able to demonstrate positive treatment outcomes in all patients in their respective case series. Finally, another retrospective case series by James and Bradley9 showed convincingly high cure rates with a significantly shorter length of stay in those patients with an uncomplicated shunt infection (that is, a single shunt system) treated with complete shunt removal together with systemic and intrathecal antibiotics (Table 4). Unfortunately, the absence of a concurrent control group treated with shunt removal and systemic antibiotics alone in this and other studies listed in Table 4 limits the impact of these data to the overall body of evidence.

When examining the studies presented in evidence in Table 32,10,20,34 and Table 4,8,9,13–15,21,24,26,30,31 it is difficult to say with any degree of clinical certainty whether complete shunt removal leads to better shunt infection treatment outcomes than partial shunt removal. This is due, in part, to the paucity of outcome data comparing the 2 treatment options within the same study population, but also to the confounding effect of intrathecal antibiotic therapy, as described above.

After a full-text review of the contents of papers that were initially identified through our search strategy or our scrutiny of reference lists, predefined criteria led to the exclusion of multiple studies from the evidentiary tables. The recommendations provided above are not materially changed by the exclusion of these studies.

Conclusions

Recommendation: Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use. Strength of Recommendation: Level III, unclear degree of clinical certainty.

It appears that the optimal management of CSF shunt infection requires a multimodality approach. Review and critical appraisal of the available evidence regarding the management of ventricular shunt infection allow for a recommendation for the supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) cannot be made, owing to severe methodological deficiencies in the existing literature. Furthermore, there is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections, or in other clinical scenarios, such as when an infected CSF shunt cannot be completely removed, must be removed and immediately replaced in the face of ongoing CSF infection, or in the setting of ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).

Deficiencies in the existing literature regarding the management of CSF shunt infection provide a strong rationale for further prospective research into the subject. Key questions that remain unanswered include, but are certainly not limited to the following:

  • Defining the optimal duration of antibiotic therapy in the management of CSF shunt infection, with the aim of simultaneously maximizing the probability of successful treatment without reinfection or relapse, and minimizing the length of hospital stay and overall cost to the health care system.

  • Refining the indications for intrathecal antibiotic therapy and ascertaining the risk/benefit profile of such therapy (potential adverse effects vs potential reduction in relapse/reinfection rates and shorter hospital stays).

  • Definition and validation of standardized treatment outcome measures, based on microbiological or other biomarker-based criteria. This would not only facilitate a comparison of results across studies, but also potentially yield objective criteria that facilitate decision making in other contentious areas of CSF shunt infection management, such as the optimal timing of shunt reimplantation.

Perhaps the best strategy to treat ventricular shunt infection is to continue our focus on the prevention of this significant complication of CSF shunt therapy.

Acknowledgments

We acknowledge the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Guidelines Committee for the members' reviews, comments, and suggestions; Laura Mitchell, Guidelines Project Manager for the CNS, for her contributions; Pamela Shaw, research librarian, for her assistance with the literature searches; Kevin Boyer for his assistance with data analysis; and Sue Ann Kawecki for her assistance with editing.

Disclosure

The systematic review and evidence-based guidelines were funded exclusively by the CNS and AANS Pediatric Section, which received no funding from outside commercial sources to support the development of this document.

Conflict(s) of Interest: None. All members of the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force declared any potential conflicts of interest prior to beginning work on this evidence review.

Author contributions to the study and manuscript preparation include the following. Conception and design: AANS/CNS Joint Section on Pediatrics. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Tamber. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Flannery. Administrative/technical/material support: all authors. Study supervision: Flannery.

References

  • 1

    Anderson EJYogev R: A rational approach to the management of ventricular shunt infections. Pediatr Infecti Dis J 24:5575582005

  • 2

    Arnell KEnblad PWester TSjölin J: Treatment of cerebrospinal fluid shunt infections in children using systemic and intraventricular antibiotic therapy in combination with externalization of the ventricular catheter: efficacy in 34 consecutively treated infections. J Neurosurg 107:3 Suppl2132192007

    • Search Google Scholar
    • Export Citation
  • 3

    Bayston RRickwood AM: Factors involved in the antibiotic treatment of cerebrospinal fluid shunt infections. Z Kinderchir 34:3393451981

    • Search Google Scholar
    • Export Citation
  • 4

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

  • 5

    Flannery AMMitchell L: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: Introduction and methodology. J Neurosurg Pediatr (Suppl) 14:372014

    • Search Google Scholar
    • Export Citation
  • 6

    Forrest DMTabara ZBTowu ESaid AJ: Management of the colonised shunt. Z Kinderchir 42:Suppl 121221987

  • 7

    Gutiérrez-González RBoto GRPérez-Zamarrón A: Cerebrospinal fluid diversion devices and infection. A comprehensive review. Eur J Clin Microbiol Infect Dis 31:8898972012

    • Search Google Scholar
    • Export Citation
  • 8

    James HEBejar RGluck LCoen RMerritt AMannino F: Ventriculoperitoneal shunts in high risk newborns weighing under 2000 grams: a clinical report. Neurosurgery 15:1982021984

    • Search Google Scholar
    • Export Citation
  • 9

    James HEBradley JS: Aggressive management of shunt infection: combined intravenous and intraventricular antibiotic therapy for twelve or less days. Pediatr Neurosurg 44:1041112008

    • Search Google Scholar
    • Export Citation
  • 10

    James HEBradley JS: Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr 1:2232282008

  • 11

    James HEWalsh JWWilson HDConnor JD: The management of cerebrospinal fluid shunt infections: a clinical experience. Acta Neurochir (Wien) 59:1571661981

    • Search Google Scholar
    • Export Citation
  • 12

    James HEWalsh JWWilson HDConnor JDBean JRTibbs PA: Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 7:4594631980

    • Search Google Scholar
    • Export Citation
  • 13

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

    • Search Google Scholar
    • Export Citation
  • 14

    Kontny UHöfling BGutjahr PVoth DSchwarz MSchmitt HJ: CSF shunt infections in children. Infection 21:89921993

  • 15

    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
  • 16

    McLaurin RL: Treatment of infected ventricular shunts. Childs Brain 1:3063101975

  • 17

    Morrice JJYoung DG: Bacterial colonisation of Holter valves: a ten-year survey. Dev Med Child Neurol 16:6 Suppl 3285901974

  • 18

    Nicholas JLKamal IMEckstein HB: Immediate shunt replacement in the treatment of bacterial colonisation of Holter valves. Dev Med Child Neurol 12:Suppl 221101131970

    • Search Google Scholar
    • Export Citation
  • 19

    Odio CMcCracken GH JrNelson JD: CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 138:110311081984

  • 20

    Ronan AHogg GGKlug GL: Cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J 14:7827861995

  • 21

    Scarff TBNelson PBReigel DH: External drainage for ventricular infection following cerebrospinal fluid shunts. Childs Brain 4:1291361978

    • Search Google Scholar
    • Export Citation
  • 22

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

    • Search Google Scholar
    • Export Citation
  • 23

    Schreffler RTSchreffler AJWittler RR: Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J 21:6326362002

    • Search Google Scholar
    • Export Citation
  • 24

    Schuhmann MUOstrowski KRDraper EJChu JWHam SDSood S: The value of C-reactive protein in the management of shunt infections. J Neurosurg 103:3 Suppl2232302005

    • Search Google Scholar
    • Export Citation
  • 25

    Sells CJShurtleff DBLoeser JD: Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics 59:6146181977

  • 26

    Shimizu TLuciano MGFukuhara T: Role of endoscopic third ventriculostomy at infected cerebrospinal fluid shunt removal. Clinical article. J Neurosurg Pediatr 9:3203262012

    • Search Google Scholar
    • Export Citation
  • 27

    Shurtleff DBFoltz ELWeeks RDLoeser J: Therapy of Staphylococcus epidermidis: infections associated with cerebrospinal fluid shunts. Pediatrics 53:55621974

    • 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

    • Search Google Scholar
    • Export Citation
  • 29

    Simon TDRiva-Cambrin JSrivastava RBratton SLDean JMKestle JR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr 1:1311372008

    • Search Google Scholar
    • Export Citation
  • 30

    Stamos JKKaufman BAYogev R: Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:8588621993

  • 31

    Turgut MAlabaz DErbey FKocabas EErman TAlhan E: Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 41:1311362005

    • Search Google Scholar
    • Export Citation
  • 32

    Wald SLMcLaurin RL: Cerebrospinal fluid antibiotic levels during treatment of shunt infections. J Neurosurg 52:41461980

  • 33

    Walters BCHoffman HJHendrick EBHumphreys RP: Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 60:101410211984

    • Search Google Scholar
    • Export Citation
  • 34

    Wang KCLee HJSung JNCho BK: Cerebrospinal fluid shunt infection in children: efficiency of management protocol, rate of persistent shunt colonization, and significance of 'off-antibiotics' trial. Childs Nerv Syst 15:38441999

    • Search Google Scholar
    • Export Citation
  • 35

    Whitehead WEKestle JR: The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons. Pediatr Neurosurg 35:2052102001

    • Search Google Scholar
    • Export Citation
  • 36

    Working Party on the Use of Antibiotics in Neurosurgery of the British Society for Antimicrobial Chemotherapy: Treatment of infections associated with shunting for hydrocephalus. Br J Hosp Med 53:3683731995

    • Search Google Scholar
    • Export Citation
  • 37

    Yogev R: Cerebrospinal fluid shunt infections: a personal view. Pediatr Infect Dis 4:1131181985

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Article Information

Address correspondence to: Ann Marie Flannery, M.D., Department of Neurological Surgery, Saint Louis University, 3565 Vista Ave., St. Louis, MO 63110. email: flanneam@slu.edu.

Please include this information when citing this paper: DOI: 10.3171/2014.7.PEDS14328.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Organization of evidentiary tables based on alternative paradigms for the management of CSF shunt infection.

  • View in gallery

    Flowchart showing the process involved in identifying relevant literature.

References

  • 1

    Anderson EJYogev R: A rational approach to the management of ventricular shunt infections. Pediatr Infecti Dis J 24:5575582005

  • 2

    Arnell KEnblad PWester TSjölin J: Treatment of cerebrospinal fluid shunt infections in children using systemic and intraventricular antibiotic therapy in combination with externalization of the ventricular catheter: efficacy in 34 consecutively treated infections. J Neurosurg 107:3 Suppl2132192007

    • Search Google Scholar
    • Export Citation
  • 3

    Bayston RRickwood AM: Factors involved in the antibiotic treatment of cerebrospinal fluid shunt infections. Z Kinderchir 34:3393451981

    • Search Google Scholar
    • Export Citation
  • 4

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

  • 5

    Flannery AMMitchell L: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 1: Introduction and methodology. J Neurosurg Pediatr (Suppl) 14:372014

    • Search Google Scholar
    • Export Citation
  • 6

    Forrest DMTabara ZBTowu ESaid AJ: Management of the colonised shunt. Z Kinderchir 42:Suppl 121221987

  • 7

    Gutiérrez-González RBoto GRPérez-Zamarrón A: Cerebrospinal fluid diversion devices and infection. A comprehensive review. Eur J Clin Microbiol Infect Dis 31:8898972012

    • Search Google Scholar
    • Export Citation
  • 8

    James HEBejar RGluck LCoen RMerritt AMannino F: Ventriculoperitoneal shunts in high risk newborns weighing under 2000 grams: a clinical report. Neurosurgery 15:1982021984

    • Search Google Scholar
    • Export Citation
  • 9

    James HEBradley JS: Aggressive management of shunt infection: combined intravenous and intraventricular antibiotic therapy for twelve or less days. Pediatr Neurosurg 44:1041112008

    • Search Google Scholar
    • Export Citation
  • 10

    James HEBradley JS: Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr 1:2232282008

  • 11

    James HEWalsh JWWilson HDConnor JD: The management of cerebrospinal fluid shunt infections: a clinical experience. Acta Neurochir (Wien) 59:1571661981

    • Search Google Scholar
    • Export Citation
  • 12

    James HEWalsh JWWilson HDConnor JDBean JRTibbs PA: Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 7:4594631980

    • Search Google Scholar
    • Export Citation
  • 13

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

    • Search Google Scholar
    • Export Citation
  • 14

    Kontny UHöfling BGutjahr PVoth DSchwarz MSchmitt HJ: CSF shunt infections in children. Infection 21:89921993

  • 15

    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
  • 16

    McLaurin RL: Treatment of infected ventricular shunts. Childs Brain 1:3063101975

  • 17

    Morrice JJYoung DG: Bacterial colonisation of Holter valves: a ten-year survey. Dev Med Child Neurol 16:6 Suppl 3285901974

  • 18

    Nicholas JLKamal IMEckstein HB: Immediate shunt replacement in the treatment of bacterial colonisation of Holter valves. Dev Med Child Neurol 12:Suppl 221101131970

    • Search Google Scholar
    • Export Citation
  • 19

    Odio CMcCracken GH JrNelson JD: CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 138:110311081984

  • 20

    Ronan AHogg GGKlug GL: Cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J 14:7827861995

  • 21

    Scarff TBNelson PBReigel DH: External drainage for ventricular infection following cerebrospinal fluid shunts. Childs Brain 4:1291361978

    • Search Google Scholar
    • Export Citation
  • 22

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

    • Search Google Scholar
    • Export Citation
  • 23

    Schreffler RTSchreffler AJWittler RR: Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J 21:6326362002

    • Search Google Scholar
    • Export Citation
  • 24

    Schuhmann MUOstrowski KRDraper EJChu JWHam SDSood S: The value of C-reactive protein in the management of shunt infections. J Neurosurg 103:3 Suppl2232302005

    • Search Google Scholar
    • Export Citation
  • 25

    Sells CJShurtleff DBLoeser JD: Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics 59:6146181977

  • 26

    Shimizu TLuciano MGFukuhara T: Role of endoscopic third ventriculostomy at infected cerebrospinal fluid shunt removal. Clinical article. J Neurosurg Pediatr 9:3203262012

    • Search Google Scholar
    • Export Citation
  • 27

    Shurtleff DBFoltz ELWeeks RDLoeser J: Therapy of Staphylococcus epidermidis: infections associated with cerebrospinal fluid shunts. Pediatrics 53:55621974

    • 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

    • Search Google Scholar
    • Export Citation
  • 29

    Simon TDRiva-Cambrin JSrivastava RBratton SLDean JMKestle JR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr 1:1311372008

    • Search Google Scholar
    • Export Citation
  • 30

    Stamos JKKaufman BAYogev R: Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:8588621993

  • 31

    Turgut MAlabaz DErbey FKocabas EErman TAlhan E: Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 41:1311362005

    • Search Google Scholar
    • Export Citation
  • 32

    Wald SLMcLaurin RL: Cerebrospinal fluid antibiotic levels during treatment of shunt infections. J Neurosurg 52:41461980

  • 33

    Walters BCHoffman HJHendrick EBHumphreys RP: Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 60:101410211984

    • Search Google Scholar
    • Export Citation
  • 34

    Wang KCLee HJSung JNCho BK: Cerebrospinal fluid shunt infection in children: efficiency of management protocol, rate of persistent shunt colonization, and significance of 'off-antibiotics' trial. Childs Nerv Syst 15:38441999

    • Search Google Scholar
    • Export Citation
  • 35

    Whitehead WEKestle JR: The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons. Pediatr Neurosurg 35:2052102001

    • Search Google Scholar
    • Export Citation
  • 36

    Working Party on the Use of Antibiotics in Neurosurgery of the British Society for Antimicrobial Chemotherapy: Treatment of infections associated with shunting for hydrocephalus. Br J Hosp Med 53:3683731995

    • Search Google Scholar
    • Export Citation
  • 37

    Yogev R: Cerebrospinal fluid shunt infections: a personal view. Pediatr Infect Dis 4:1131181985

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