Reinfection following initial cerebrospinal fluid shunt infection

Clinical article

Tamara D. Simon M.D., M.S.P.H. 1 , Matthew Hall Ph.D. 2 , J. Michael Dean M.D., M.B.A. 3 , John R. W. Kestle M.D., M.Sc. 4 , and Jay Riva-Cambrin M.D., M.Sc. 4
View More View Less
  • 1 Divisions of Inpatient Medicine,
  • 3 Critical Care, and
  • 4 Pediatric Neurosurgery, Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
  • 2 Child Health Corporation of America, Shawnee Mission, Kansas
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Significant variation exists in the surgical and medical management of CSF shunt infection. The objectives of this study were to determine CSF shunt reinfection rates following initial CSF shunt infection in a large patient cohort and to determine management, patient, hospital, and surgeon factors associated with CSF shunt reinfection.

Methods

This retrospective cohort study included children who were in the Pediatric Health Information System (PHIS) database, who ranged in age from 0 to 18 years, and who underwent uncomplicated initial CSF shunt placement in addition to treatment for initial CSF shunt infection between January 1, 2001, and December 31, 2008. The outcome was CSF shunt reinfection within 6 months. The main predictor variable of interest was surgical approach to treatment of first infection, which was determined for 483 patients. Covariates included patient, hospital, surgeon, and other management factors.

Results

The PHIS database includes 675 children with initial CSF shunt infection. Surgical approach to treatment of the initial CSF shunt infection was determined for 483 children (71.6%). The surgical approach was primarily shunt removal/new shunt placement (in 286 children [59.2%]), but a substantial number underwent externalization (59 children [12.2%]), of whom a subset went on to have the externalized shunt removed and a new shunt placed (17 children [3.5% overall]). Other approaches included nonsurgical management (64 children [13.3%]) and complete shunt removal without shunt replacement (74 children [15.3%]).

The 6-month reinfection rate was 14.8% (100 of 675 patients). The median time from infection to reinfection was 21 days (interquartile range [IQR] 5–58 days). Children with reinfection had less time between shunt placement and initial infection (median 50 vs 79 days, p = 0.06). No differences between those with and without reinfection were seen in patient factors (patient age at either shunt placement or initial infection, sex, race/ethnicity, payer, indication for shunt, number of comorbidities, distal shunt location, and number of shunt revisions at first infection); hospital volume; surgeon volume; or other management factors (for example, duration of intravenous antibiotic use). Nonsurgical management was associated with reinfection, and complete shunt removal was negatively associated with reinfection. However, reinfection rates did not differ between the 2 most common surgical approaches: shunt removal/new shunt placement (44 [15.4%] of 286; 95% CI 11.4%–20.1%) and externalization (total 12 [20.3%] of 59; 95% CI 11.0%–32.8%). Externalization followed by shunt removal/new shunt placement (5 [29.4%] of 17; 95% CI 10.3%–56.0%) and nonsurgical management (15 [23.4%] of 64; 95% CI 13.8%–35.7%) had higher, but nonstatistically significant, reinfection rates. The length of stay was shorter for nonsurgical management.

Conclusions

Surgical approach to treatment of initial CSF shunt infection was not associated with reinfection in this large cohort of patients.

Abbreviations used in this paper: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; IQR = interquartile range; IVH = intraventricular hemorrhage; LOS = length of stay; PHIS = Pediatric Health Information System; VP = ventriculoperitoneal.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Tamara Simon, M.D., M.S.P.H., University of Washington, Department of Pediatrics, Division of Hospital Medicine, Office 581, Seattle Children's Research Institute, Building 1, 1900 Ninth Avenue, Seattle, Washington 98101. email: Tamara.Simon@hsc.utah.edu.
  • 1

    Albert JE, , Simon TD, , Hall M, , Kestle J, & Jeffries HE: Improved identification of pediatric neurosurgical procedure infections. Pediatric Academic Societies Annual Meeting Honolulu, Hawaii May 2–6, 2008 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 2

    Bayston R, , Barnicoat M, , Cudmore RE, , Guiney EJ, , Gurusinghe N, & Norman PM: The use of intraventricular vancomycin in the treatment of CSF shunt-associated ventriculitis. Z Kinderchir 39:Suppl 2 111113, 1984

    • Search Google Scholar
    • Export Citation
  • 3

    Brown EM, , Edwards RJ, & Pople IK: Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery 58:657665, 2006

    • Search Google Scholar
    • Export Citation
  • 4

    Cruciani M, , Navarra A, , Di Perri G, , Andreoni M, , Danzi MC, & Concia E, : Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections. Clin Infect Dis 15:285289, 1992

    • Search Google Scholar
    • Export Citation
  • 5

    Fan-Havard P, & Nahata MC: Treatment and prevention of infections of cerebrospinal fluid shunts. Clin Pharm 6:866880, 1987

  • 6

    Fernández Guerrero ML, , de Górgolas M, , Fernández Roblas R, & Campos JM: Treatment of cerebrospinal fluid shunt infections with teicoplanin. Eur J Clin Microbiol Infect Dis 13:10561058, 1994

    • Search Google Scholar
    • Export Citation
  • 7

    Feudtner C, , Christakis DA, & Connell FA: Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997. Pediatrics 106:205209, 2000

    • Search Google Scholar
    • Export Citation
  • 8

    Feudtner C, , Hays RM, , Haynes G, , Geyer JR, , Neff JM, & Koepsell TD: Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services. Pediatrics 107:E99, 2001

    • Search Google Scholar
    • Export Citation
  • 9

    Frame PT, & McLaurin RL: Treatment of CSF shunt infections with intrashunt plus oral antibiotic therapy. J Neurosurg 60:354360, 1984

  • 10

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

  • 11

    Gardner P, , Leipzig TJ, & Sadigh M: Infections of mechanical cerebrospinal fluid shunts. Curr Clin Top Infect Dis 9:185214, 1988

  • 12

    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
  • 13

    Greene KA, , Clark RJ, & Zabramski JM: Ventricular CSF shunt infections associated with Corynebacterium jeikeium: report of three cases and review. Clin Infect Dis 16:139141, 1993

    • Search Google Scholar
    • Export Citation
  • 14

    Jamjoom A, , al-Abedeen Jamjoom Z, , al-Hedaithy S, , Jamali A, , Naim-Ur-Rahman & Malabarey T: Ventriculitis and hydrocephalus caused by Candida albicans successfully treated by antimycotic therapy and cerebrospinal fluid shunting. Br J Neurosurg 6:501504, 1992

    • Search Google Scholar
    • Export Citation
  • 15

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

  • 16

    Katz MD, , Rapp RP, & Walsh JW: Infection in a functioning ventriculoperitoneal shunt treated with intraventricular gentamicin. Am J Hosp Pharm 37:268271, 1980

    • Search Google Scholar
    • Export Citation
  • 17

    Kestle JR: Pediatric hydrocephalus: current management. Neurol Clin 21:883895, vii, 2003

  • 18

    Kestle JR, , Garton HJ, , Whitehead WE, , Drake JM, , Kulkarni AV, & Cochrane DD, : Management of shunt infections: a multicenter pilot study. J Neurosurg 105:3 Suppl 177181, 2006

    • Search Google Scholar
    • Export Citation
  • 19

    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
  • 20

    Kulkarni AV, , Rabin D, , Lamberti-Pasculli M, & Drake JM: Repeat cerebrospinal fluid shunt infection in children. Pediatr Neurosurg 35:6671, 2001

    • Search Google Scholar
    • Export Citation
  • 21

    Li V, & Dias MS: The results of a practice survey on the management of patients with shunted hydrocephalus. Pediatr Neurosurg 30:288295, 1999

    • Search Google Scholar
    • Export Citation
  • 22

    McCarthy EP, , Iezzoni LI, , Davis RB, , Palmer RH, , Cahalane M, & Hamel MB, : Does clinical evidence support ICD-9-CM diagnosis coding of complications?. Med Care 38:868876, 2000

    • Search Google Scholar
    • Export Citation
  • 23

    McGirt MJ, , Leveque JC, , Wellons JC III, , Villavicencio AT, , Hopkins JS, & Fuchs HE, : Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg 36:248255, 2002

    • Search Google Scholar
    • Export Citation
  • 24

    McLaurin RL: Treatment of infected ventricular shunts. Childs Brain 1:306310, 1975

  • 25

    Morissette I, , Gourdeau M, & Francoeur J: CSF shunt infections: a fifteen-year experience with emphasis on management and outcome. Can J Neurol Sci 20:118122, 1993

    • Search Google Scholar
    • Export Citation
  • 26

    Nelson JD: Cerebrospinal fluid shunt infections. Pediatr Infect Dis 3:3 Suppl S30S32, 1984

  • 27

    Odio C, , McCracken GH Jr, & Nelson JD: CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 138:11031108, 1984

  • 28

    Pickering LK, , Ericsson CD, , Ruiz-Palacios G, , Blevins J, & Miner ME: Intraventricular and parenteral gentamicin therapy for ventriculitis in children. Am J Dis Child 132:480483, 1978

    • Search Google Scholar
    • Export Citation
  • 29

    Quinn AL, , Parada JP, , Belmares J, & O'Keefe JP: Intrathecal colistin and sterilization of resistant Pseudomonas aeruginosa shunt infection. Ann Pharmacother 39:949952, 2005

    • Search Google Scholar
    • Export Citation
  • 30

    Segal-Maurer S, , Mariano N, , Qavi A, , Urban C, & Rahal JJ Jr: Successful treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis with intravenous meropenem and intraventricular polymyxin B: case report and review. Clin Infect Dis 28:11341138, 1999

    • Search Google Scholar
    • Export Citation
  • 31

    Sells CJ, , Shurtleff DB, & Loeser JD: Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics 59:614618, 1977

  • 32

    Simon TD, , Hall M, , Riva-Cambrin J, , Albert JE, , Jeffries HE, & Lafleur B, : Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:156165, 2009

    • Search Google Scholar
    • Export Citation
  • 33

    Simon TD, , Riva-Cambrin J, , Srivastava R, , Bratton SL, , Dean JM, & Kestle JR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr 1:131137, 2008

    • Search Google Scholar
    • Export Citation
  • 34

    Swayne R, , Rampling A, & Newsom SW: Intraventricular vancomycin for treatment of shunt-associated ventriculitis. J Antimicrob Chemother 19:249253, 1987

    • Search Google Scholar
    • Export Citation
  • 35

    Venes JL: Infections of CSF shunt and intracranial pressure monitoring devices. Infect Dis Clin North Am 3:289299, 1989

  • 36

    Vinchon M, & Dhellemmes P: Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:692697, 2006

  • 37

    Walters BC, , Hoffman HJ, , Hendrick EB, & Humphreys RP: Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 60:10141021, 1984

    • Search Google Scholar
    • Export Citation
  • 38

    Wen DY, , Bottini AG, , Hall WA, & Haines SJ: Infections in neurologic surgery. The intraventricular use of antibiotics. Neurosurg Clin N Am 3:343354, 1992

    • Search Google Scholar
    • Export Citation
  • 39

    Whitehead WE, & Kestle JR: The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons. Pediatr Neurosurg 35:205210, 2001

    • Search Google Scholar
    • Export Citation
  • 40

    Williams MA, , McAllister JP, , Walker ML, , Kranz DA, , Bergsneider M, & Del Bigio MR, : Priorities for hydrocephalus research: report from a National Institutes of Health-sponsored workshop. J Neurosurg 5 Suppl 345357, 2007

    • Search Google Scholar
    • Export Citation
  • 41

    Younger JJ, , Christensen GD, , Bartley DL, , Simmons JC, & Barrett FF: Coagulase-negative staphylococci isolated from cerebrospinal fluid shunts: importance of slime production, species identification, and shunt removal to clinical outcome. J Infect Dis 156:548554, 1987

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 581 116 5
Full Text Views 139 4 0
PDF Downloads 112 5 0
EPUB Downloads 0 0 0