Infection risk for Bactiseal Universal Shunts versus Chhabra shunts in Ugandan infants: a randomized controlled trial

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  • 1 CURE Children’s Hospital, Mbale, Uganda;
  • 2 Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;
  • 3 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania;
  • 4 Warren Alpert Medical School, Brown University, Providence, Rhode Island;
  • 5 Department of Neurosurgery, Boston Children’s Hospital;
  • 6 Department of Neurology, Harvard Medical School, Harvard University; and
  • 7 Clinical Research Center, Boston Children’s Hospital, Boston, Massachusetts
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OBJECTIVE

Clinical and economic repercussions of ventricular shunt infections are magnified in low-resource countries. The efficacy of antibiotic-impregnated shunts in this setting is unclear. A previous retrospective cohort study comparing the Bactiseal Universal Shunt (BUS) and the Chhabra shunt provided clinical equipoise; thus, the authors conducted this larger randomized controlled trial in Ugandan children requiring shunt placement for hydrocephalus to determine whether there was, in fact, any advantage of one shunt over the other.

METHODS

Between April 2013 and September 2016, the authors randomly assigned children younger than 16 years of age without evidence of ventriculitis to either BUS or Chhabra shunt implantation in this single-blind randomized controlled trial. The primary outcome was shunt infection, and secondary outcomes included reoperation and death. The minimum follow-up was 6 months. Time to outcome was assessed using the Kaplan-Meier method. The significance of differences was tested using Wilcoxon rank-sum, chi-square, Fisher’s exact, and t-tests.

RESULTS

Of the 248 patients randomized, the BUS was implanted in 124 and the Chhabra shunt in 124. There were no differences between the groups in terms of age, sex, or hydrocephalus etiology. Within 6 months of follow-up, there were 14 infections (5.6%): 6 BUS (4.8%) and 8 Chhabra (6.5%; p = 0.58). There were 14 deaths (5.6%; 5 BUS [4.0%] vs 9 Chhabra [7.3%], p = 0.27) and 30 reoperations (12.1%; 15 BUS vs 15 Chhabra, p = 1.00). There were no significant differences in the time to primary or secondary outcomes at 6 months’ follow-up (p = 0.29 and 0.17, respectively, Wilcoxon rank-sum test).

CONCLUSIONS

Among Ugandan infants, BUS implantation did not result in a lower incidence of shunt infection or other complications. Any recommendation for a more costly standard of care in low-resource countries must have contextually relevant, evidence-based support.

Clinical trial registration no.: PACTR201804003240177 (http://www.pactr.org/)

ABBREVIATIONS AIS = antibiotic-impregnated shunt; BUS = Bactiseal Universal Shunt; CCHU = CURE Children’s Hospital of Uganda; CNS = central nervous system; CSF = cerebrospinal fluid; HIC = high-income country; LMIC = low- and middle-income countries; NPIH = non-postinfectious hydrocephalus; PIH = postinfectious hydrocephalus; RCT = randomized controlled trial; WBC = white blood cell.

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Contributor Notes

Correspondence Benjamin C. Warf: Boston Children’s Hospital, Boston, MA. benjamin.warf@childrens.harvard.edu.

INCLUDE WHEN CITING Published online January 4, 2019; DOI: 10.3171/2018.10.PEDS18354.

Disclosures All BUS systems were provided at no cost by Codman, which also provided funding support. Chhabra shunts were provided at no cost by the nonprofit group the International Federation for Spina Bifida and Hydrocephalus (www.ifglobal.org). Neither entity had any role in the design of the study, collection or analysis of the data, data interpretation, or writing or editing the manuscript. The corresponding author had full access to the data and final responsibility for the submission of the manuscript for publication. None of the authors has any conflicts of interest to report, financial or otherwise.

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