A standardized protocol to reduce cerebrospinal fluid shunt infection: The Hydrocephalus Clinical Research Network Quality Improvement Initiative

Clinical article

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  • 1 Primary Children's Medical Center, University of Utah, Salt Lake City, Utah;
  • 2 Birmingham Children's Hospital, University of Alabama, Birmingham, Alabama;
  • 3 Hospital for Sick Children, University of Toronto, Ontario, Canada;
  • 4 Texas Children's Hospital, Baylor College of Medicine, Houston, Texas;
  • 5 Seattle Children's Research Institute, University of Washington, Seattle, Washington; and
  • 6 Hydrocephalus Clinical Research Network Data Coordinating Center, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Object

Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).

Methods

The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.

Results

Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19–3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43–14.41; p = 0.01) were associated with an increased risk of infection.

Conclusions

The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.

Abbreviations used in this paper: EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network.

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Contributor Notes

Address correspondence to: John R. W. Kestle, M.D., Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children's Medical Center, University of Utah, 100 Mario Capecchi Drive, Suite 1475, Salt Lake City, Utah 84113. email: john.kestle@hsc.utah.edu.
  • 1

    Arthur AS, , Whitehead WE, & Kestle JRW: Duration of antibiotic therapy for the treatment of shunt infection: a surgeon and patient survey. Pediatr Neurosurg 36:256259, 2002

    • Search Google Scholar
    • Export Citation
  • 2

    Cochrane D, , Kestle J, , Steinbok P, , Evans D, & Heron N: Model for the cost analysis of shunted hydrocephalic children. Pediatr Neurosurg 23:1419, 1995

    • Search Google Scholar
    • Export Citation
  • 3

    Darouiche RO, , Wall MJ Jr, , Itani KM, , Otterson MF, , Webb AL, & Carrick MM, : Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 362:1826, 2010

    • Search Google Scholar
    • Export Citation
  • 4

    Drake JM: Editorial. Does double gloving prevent cerebrospinal fluid shunt infection?. J Neurosurg 104:1 Suppl 34, 2006

  • 5

    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
  • 6

    Haynes AB, , Weiser TG, , Berry WR, , Lipsitz SR, , Breizat AH, & Dellinger EP, : A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491499, 2009

    • Search Google Scholar
    • Export Citation
  • 7

    Kestle J, , Drake J, , Milner R, , Sainte-Rose C, , Cinalli G, & Boop F, : Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg 33:230236, 2000

    • Search Google Scholar
    • Export Citation
  • 8

    Kestle JR, , Drake JM, , Cochrane DD, , Milner R, , Walker ML, & Abbott R III, : Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg 98:284290, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    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
  • 10

    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
  • 11

    Miller MR, , Griswold M, , Harris JM II, , Yenokyan G, , Huskins WC, & Moss M, : Decreasing PICU catheter-associated bloodstream infections: NACHRI's quality transformation efforts. Pediatrics 125:206213, 2010

    • Search Google Scholar
    • Export Citation
  • 12

    Ragel BT, , Browd SR, & Schmidt RH: Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:242247, 2006

    • Search Google Scholar
    • Export Citation
  • 13

    Rozzelle CJ, , Leonardo J, & Li V: Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial. J Neurosurg Pediatr 2:111117, 2008

    • Search Google Scholar
    • Export Citation
  • 14

    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
  • 15

    US Food Drug Administration: Medical Device Recalls: Medtronic Neurologic Technologies, Innervision Snap Shunt Ventricular Catheter, BioGlide and Snap Shunt Ventricular Catheter, BioGlide (http://www.fda.gov/MedicalDevices/Safety/RecallsCorrectionsRemovals/ListofRecalls/ucm126620.htm) [Accessed April 28, 2011]

    • Search Google Scholar
    • Export Citation
  • 16

    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

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