Reinfection rates following adherence to Infectious Diseases Society of America guideline recommendations in first cerebrospinal fluid shunt infection treatment

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OBJECTIVE

CSF shunt infection treatment requires both surgical and antibiotic decisions. Using the Hydrocephalus Clinical Research Network (HCRN) Registry and 2004 Infectious Diseases Society of America (IDSA) guidelines that were not proactively distributed to HCRN providers, the authors previously found high adherence to surgical recommendations but poor adherence to intravenous (IV) antibiotic duration recommendations. In general, IV antibiotic duration was longer than recommended. In March 2017, new IDSA guidelines expanded upon the 2004 guidelines by including recommendations for selection of specific antibiotics. The objective of this study was to describe adherence to both 2004 and 2017 IDSA guideline recommendations for CSF shunt infection treatment, and to report reinfection rates associated with adherence to guideline recommendations.

METHODS

The authors investigated a prospective cohort of children younger than 18 years of age who underwent treatment for first CSF shunt infection at one of 7 hospitals from April 2008 to December 2012. CSF shunt infection was diagnosed by recovery of bacteria from CSF culture (CSF-positive infection). Adherence to 2004 and 2017 guideline recommendations was determined. Adherence to antibiotics was further classified as longer or shorter duration than guideline recommendations. Reinfection rates with 95% confidence intervals (CIs) were generated.

RESULTS

There were 133 children with CSF-positive infections addressed by 2004 IDSA guideline recommendations, with 124 at risk for reinfection. Zero reinfections were observed among those whose treatment was fully adherent (0/14, 0% [95% CI 0%–20%]), and 15 reinfections were observed among those whose infection treatment was nonadherent (15/110, 14% [95% CI 8%–21%]). Among the 110 first infections whose infection treatment was nonadherent, 74 first infections were treated for a longer duration than guidelines recommended and 9 developed reinfection (9/74, 12% [95% CI 6%–22%]). There were 145 children with CSF-positive infections addressed by 2017 IDSA guideline recommendations, with 135 at risk for reinfection. No reinfections were observed among children whose treatment was fully adherent (0/3, 0% [95% CI 0%–64%]), and 18 reinfections were observed among those whose infection treatment was nonadherent (18/132, 14% [95% CI 8%–21%]).

CONCLUSIONS

There is no clear evidence that either adherence to IDSA guidelines or duration of treatment longer than recommended is associated with reduction in reinfection rates. Because IDSA guidelines recommend shorter IV antibiotic durations than are typically used, improvement efforts to reduce IV antibiotic use in CSF shunt infection treatment can and should utilize IDSA guidelines.

ABBREVIATIONS CI = confidence interval; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; IDSA = Infectious Diseases Society of America; IV = intravenous.

Article Information

Correspondence Tamara Simon: University of Washington, Seattle, WA. tamara.simon@seattlechildrens.org.

INCLUDE WHEN CITING Published online February 15, 2019; DOI: 10.3171/2018.11.PEDS18373.

Disclosures Dr. Limbrick reports support of non–study-related clinical or research effort from Microbot Medical, Inc. Dr. Simon and the Nemeth family, and Ms. Whitlock, were supported by Award K23NS062900 from NINDS and Seattle Children’s Center for Clinical and Translational Research, and CTSA grant no. ULI RR025014 from the National Center for Research Resources, a component of the NIH. Dr. Limbrick was supported by grants from NINDS, Patient Centered Outcomes Research Institute, the Hydrocephalus Association, Rudy Schulte, and research funding through Medtronic and Karl Storz.

© AANS, except where prohibited by US copyright law.

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    Cohort definition.

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    The 2004 IDSA guideline recommendation adherence and reinfection observed in the study cohort. Cx = cultures.

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