Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial

Curtis J. Rozzelle M.D., Jody Leonardo M.D., and Veetai Li M.D.
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  • Women and Children's Hospital of Buffalo, Kaleida Health, Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
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Object

Implantation of cerebrospinal fluid (CSF) shunting devices is associated with a 5–15% risk of infection as cited in contemporary pediatric neurosurgical literature. Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement. Moreover, shunt infections are commonly associated with prolonged hospital stays, potential comorbidity, and the increased risk of neurological compromise due to ventriculitis or surgical complications. The authors prospectively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture (AMS) or conventional suture.

Methods

In a single-center, prospective, double-blinded, randomized controlled trial, the authors enrolled 61 patients, among whom 84 CSF shunt procedures were performed over 21 months. Randomization to the study (AMS) or control (placebo) group was stratified to minimize the effect of known shunt infection risk factors on the findings. Antibacterial shunt components were not used. The primary outcome measure was the incidence of shunt infection within 6 months of surgery.

Results

The shunt infection rate in the study group was 2 (4.3%) of 46 procedures and 8 (21%) of 38 procedures in the control group (p = 0.038). There were no statistically significant differences in shunt infection risk factors between the groups (procedure type and time, age < 6 months, weight < 4 kg, recent history of shunt infection). No suture-related adverse events were reported in either group.

Conclusions

These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe, effective, and may be associated with a reduced risk of postoperative shunt infection. A larger randomized controlled trial is needed to confirm this association.

Abbreviations used in this paper:

AMS = antimicrobial suture; CI = confidence interval; CSF = cerebrospinal fluid; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive S. aureus; VA = ventriculoatrial; VP = ventriculoperitoneal; VPl = ventriculopleural.

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  • 1

    Akiyama H, , Torigoe R, & Arata J: Interaction of Staphylococcus aureus cells and silk threads in vitro and in mouse skin. J Dermatol Sci 6:247257, 1993

    • Search Google Scholar
    • Export Citation
  • 2

    Ammirati M, & Raimondi AJ: Cerebrospinal fluid shunt infections in children. A study on the relationship between the etiology of hydrocephalus, age at the time of shunt placement, and infection rate. Childs Nerv Syst 3:106109, 1987

    • Search Google Scholar
    • Export Citation
  • 3

    Barbolt TA: Chemistry and safety of triclosan, and its use as an antimicrobial coating on Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 suture with triclosan). Surg Infect (Larchmt) 3:1 Suppl S45S53, 2002

    • Search Google Scholar
    • Export Citation
  • 4

    Bayston R, & Lari J: A study of the sources of infection in colonised shunts. Dev Med Child Neurol 16:6 Suppl 1622, 1974

  • 5

    Blount JP, , Campbell JA, & Haines SJ: Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin N Am 4:633656, 1993

  • 6

    Bondurant CP, & Jimenez DF: Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg 23:254259, 1995

  • 7

    Borges LF: Cerebrospinal fluid shunts interfere with host defenses. Neurosurgery 10:5560, 1982

  • 8

    Chadduck W, & Adametz J: Incidence of seizures in patients with myelomeningocele: a multifactorial analysis. Surg Neurol 30:281285, 1988

    • Search Google Scholar
    • Export Citation
  • 9

    Choux M, , Genitori L, , Lang D, & Lena G: Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:875880, 1992

  • 10

    Chu CC, & Williams DF: Effects of physical configuration and chemical structure of suture materials on bacterial adhesion. A possible link to wound infection. Am J Surg 147:197204, 1984

    • Search Google Scholar
    • Export Citation
  • 11

    Cochrane DD, & Kestle JR: The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg 38:295301, 2003

    • Search Google Scholar
    • Export Citation
  • 12

    Drake JM, , Kestle JR, , Milner R, , Cinalli G, , Boop F, & Piatt J Jr, et al.: Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 43:294305, 1998

    • Search Google Scholar
    • Export Citation
  • 13

    Edmiston CE, , Seabrook GR, , Goheen MP, , Krepel CJ, , Johnson CP, & Lewis BD, et al.: Bacterial adherence to surgical sutures: can antibacterial-coated sutures reduce the risk of microbial contamination?. J Am Coll Surg 203:481489, 2006

    • Search Google Scholar
    • Export Citation
  • 14

    Elek SD, & Conen PE: The virulence of Staphylococcus pyogenes for man; a study of the problems of wound infection. Br J Exp Pathol 38:573586, 1957

    • Search Google Scholar
    • Export Citation
  • 15

    Fleck T, , Moidl R, , Blacky A, , Fleck M, , Wolner E, & Grabenwoger M, et al.: Triclosan-coated sutures for the reduction of sternal wound infections: economic considerations. Ann Thorac Surg 84:232236, 2007

    • Search Google Scholar
    • Export Citation
  • 16

    Ford HR, , Jones P, , Gaines B, , Reblock K, & Simpkins DL: Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture). Surg Infect (Larchmt) 6:313321, 2005

    • Search Google Scholar
    • Export Citation
  • 17

    Gardner P, , Leipzig T, & Phillips P: Infections of central nervous system shunts. Med Clin North Am 69:297314, 1985

  • 18

    George R, , Leibrock L, & Epstein M: Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg 51:804811, 1979

    • Search Google Scholar
    • Export Citation
  • 19

    Gilbert P, & McBain AJ: Literature-based evaluation of the potential risks associated with impregnation of medical devices and implants with triclosan. Surg Infect (Larchmt) 3:1 Suppl S55S63, 2002

    • Search Google Scholar
    • Export Citation
  • 20

    Gómez-Alonso A, , García-Criado FJ, , Parreño-Manchado FC, , García-Sánchez JE, , García-Sánchez E, & Parreño-Manchado A, et al.: Study of the efficacy of coated VICRYL plus antibacterial suture (coated Polyglactin 910 suture with Triclosan) in two animal models of general surgery. J Infect 54:8288, 2007

    • Search Google Scholar
    • Export Citation
  • 21

    Govender ST, , Nathoo N, & van Dellen JR: Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg 99:831839, 2003

    • Search Google Scholar
    • Export Citation
  • 22

    Haines SJ, & Walters BC: Antibiotic prophylaxis for cerebrospinal fluid shunts: a metanalysis. Neurosurgery 34:8792, 1994

  • 23

    Hampl J, , Schierholz J, , Jansen B, & Aschoff A: In vitro and in vivo efficacy of a rifampin-loaded silicone catheter for the prevention of CSF shunt infections. Acta Neurochir (Wien) 133:147152, 1995

    • Search Google Scholar
    • Export Citation
  • 24

    Horgan MA, & Piatt JH Jr: Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 26:180184, 1997

    • Search Google Scholar
    • Export Citation
  • 25

    Kan P, & Kestle J: Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst 23:773777, 2007

    • Search Google Scholar
    • Export Citation
  • 26

    Kanev PM, & Sheehan JM: Reflections on shunt infection. Pediatr Neurosurg 39:285290, 2003

  • 27

    Katz S, , Izhar M, & Mirelman D: Bacterial adherence to surgical sutures. A possible factor in suture induced infection. Ann Surg 194:3541, 1981

    • Search Google Scholar
    • Export Citation
  • 28

    Kestle JR, , Hoffman HJ, , Soloniuk D, , Humphreys RP, , Drake JM, & Hendrick EB: A concerted effort to prevent shunt infection. Childs Nerv Syst 9:163165, 1993

    • Search Google Scholar
    • Export Citation
  • 29

    Kockro RA, , Hampl JA, , Jansen B, , Peters G, , Scheihing M, & Giacomelli R, et al.: Use of scanning electron microscopy to investigate the prophylactic efficacy of rifampin-impregnated CSF shunt catheters. J Med Microbiol 49:441450, 2000

    • Search Google Scholar
    • Export Citation
  • 30

    Kontny U, , Höfling B, , Gutjahr P, , Voth D, , Schwarz M, & Schmitt HJ: CSF shunt infections in children. Infection 21:8992, 1993

  • 31

    Kulkarni AV, , Drake JM, & Lamberti-Pasculli M: Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:195201, 2001

    • Search Google Scholar
    • Export Citation
  • 32

    Langley JM, , LeBlanc JC, , Drake J, & Milner R: Efficacy of antimicrobial prophylaxis in placement of cerebrospinal fluid shunts: meta-analysis. Clin Infect Dis 17:98103, 1993

    • Search Google Scholar
    • Export Citation
  • 33

    Mancao M, , Miller C, , Cochrane B, , Hoff C, , Sauter K, & Weber E: Cerebrospinal fluid shunt infections in infants and children in Mobile, Alabama. Acta Paediatr 87:667670, 1998

    • Search Google Scholar
    • Export Citation
  • 34

    McGirt MJ, , Zaas A, , Fuchs HE, , George TM, , Kaye K, & Sexton DJ: Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 36:858862, 2003

    • Search Google Scholar
    • Export Citation
  • 35

    McLone DG, , Czyzewski D, , Raimondi AJ, & Sommers RC: Central nervous system infections as a limiting factor in the intelligence of children with myelomeningocele. Pediatrics 70:338342, 1982

    • Search Google Scholar
    • Export Citation
  • 36

    Moores L, & Ellenbogen R, Cerebrospinal fluid shunt infections. Hall WA, & McCutcheon IE: Infections in Neurosurgery Park Ridge, AANS, 2000. 141154

    • Search Google Scholar
    • Export Citation
  • 37

    Pattavilakom A, , Kotasnas D, , Korman TM, , Xenos C, & Danks A: Duration of in vivo antimicrobial activity of antibiotic-impregnated cerebrospinal fluid catheters. Neurosurgery 58:930935, 2006

    • Search Google Scholar
    • Export Citation
  • 38

    Pattavilakom A, , Xenos C, , Bradfield O, & Danks RA: Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J Clin Neurosci 14:526531, 2007

    • Search Google Scholar
    • Export Citation
  • 39

    Pople IK, , Bayston R, & Hayward RD: Infection of cerebrospinal fluid shunts in infants: a study of etiological factors. J Neurosurg 77:2936, 1992

    • Search Google Scholar
    • Export Citation
  • 40

    Ratilal B, , Costa J, & Sampaio C: Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 3:CD005365, 2006

    • Search Google Scholar
    • Export Citation
  • 41

    Renier D, , Lacombe J, , Pierre-Kahn A, , Sainte-Rose C, & Hirsch JF: Factors causing acute shunt infection. Computer analysis of 1174 operations. J Neurosurg 61:10721078, 1984

    • Search Google Scholar
    • Export Citation
  • 42

    Rothenburger S, , Spangler D, , Bhende S, & Burkley D: In vitro antimicrobial evaluation of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect (Larchmt) 3:1 Suppl S79S87, 2002

    • Search Google Scholar
    • Export Citation
  • 43

    Schiff SJ, & Oakes WJ: Delayed cerebrospinal-fluid shunt infection in children. Pediatr Neurosci 15:131135, 1989

  • 44

    Sciubba DM, , Lin LM, , Woodworth GF, , McGirt MJ, , Carson B, & Jallo GI: Factors contributing to the medical costs of cerebrospinal fluid shunt infection treatment in pediatric patients with standard shunt components compared with those in patients with antibiotic impregnated components. Neurosurg Focus 22:4 E9, 2007

    • Search Google Scholar
    • Export Citation
  • 45

    Sciubba DM, , Stuart RM, , McGirt MJ, , Woodworth GF, , Samdani A, & Carson B, et al.: Effect of antibiotic-impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J Neurosurg 103:2 Suppl 131136, 2005

    • Search Google Scholar
    • Export Citation
  • 46

    Serlo W, , Fernell E, , Heikkinen E, , Anderson H, & von Wendt L: Functions and complications of shunts in different etiologies of childhood hydrocephalus. Childs Nerv Syst 6:9294, 1990

    • Search Google Scholar
    • Export Citation
  • 47

    Shapiro S, , Boaz J, , Kleiman M, , Kalsbeck J, & Mealey J: Origin of organisms infecting ventricular shunts. Neurosurgery 22:868872, 1988

  • 48

    Smith ER, , Butler WE, & Barker FG II: In-hospital mortality rates after ventriculoperitoneal shunt procedures in the United States, 1998 to 2000: relation to hospital and surgeon volume of care. J Neurosurg 100:2 Suppl Pediatrics 9097, 2004

    • Search Google Scholar
    • Export Citation
  • 49

    Storch M, , Scalzo H, , Van Lue S, & Jacinto G: Physical and functional comparison of Coated VICRYL* Plus Antibacterial Suture (coated polyglactin 910 suture with triclosan) with Coated VICRYL* Suture (coated polyglactin 910 suture). Surg Infect (Larchmt) 3:1 Suppl S65S77, 2002

    • Search Google Scholar
    • Export Citation
  • 50

    Storch ML, , Rothenburger SJ, & Jacinto G: Experimental efficacy study of coated VICRYL plus antibacterial suture in guinea pigs challenged with Staphylococcus aureus. Surg Infect (Larchmt) 5:281288, 2004

    • Search Google Scholar
    • Export Citation
  • 51

    Thompson DN, , Hartley JC, & Hayward RD: Shunt infection: is there a near-miss scenario?. J Neurosurg 106:1 Suppl 1519, 2007

  • 52

    Younger JJ, , Simmons JC, & Barrett FF: Operative related infection rates for ventriculoperitoneal shunt procedures in a children's hospital. Infect Control 8:6770, 1987

    • Search Google Scholar
    • Export Citation

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