The Hydrocephalus Clinical Research Network quality improvement initiative: the role of antibiotic-impregnated catheters and vancomycin wound irrigation

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  • 1 Division of Neurosurgery, Children’s Hospital Los Angeles, Department of Neurosurgery, University of Southern California, Los Angeles, California;
  • | 2 Department of Pediatrics, University of Utah, Salt Lake City, Utah;
  • | 3 Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada;
  • | 4 Department of Clinical Neurosciences, University of Calgary, Alberta, Canada;
  • | 5 Section of Pediatric Neurosurgery, Division of Neurosurgery, Children’s Hospital of Alabama, University of Alabama–Birmingham, Alabama;
  • | 6 Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in St. Louis, Missouri;
  • | 7 Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee;
  • | 8 Department of Neurosurgery, University of Washington, Seattle Children’s Hospital, Seattle, Washington;
  • | 9 Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas;
  • | 10 Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania;
  • | 11 Department of Pediatrics, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California;
  • | 12 Department of Surgery, Division of Neurosurgery, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada;
  • | 13 Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;
  • | 14 Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada;
  • | 15 Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado;
  • | 16 Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
  • | 17 Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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OBJECTIVE

Two previous Hydrocephalus Clinical Research Network (HCRN) studies have demonstrated that compliance with a standardized CSF shunt infection protocol reduces shunt infections. In this third iteration, a simplified protocol consisting of 5 steps was implemented. This analysis provides an updated evaluation of protocol compliance and evaluates modifiable shunt infection risk factors.

METHODS

The new simplified protocol was implemented at HCRN centers on November 1, 2016, for all shunt procedures, excluding external ventricular drains, ventricular reservoirs, and subgaleal shunts. Procedures performed through December 31, 2019, were included (38 months). Compliance with the protocol, use of antibiotic-impregnated catheters (AICs), and other variables of interest were collected at the index operation. Outcome events for a minimum of 6 months postoperatively were recorded. The definition of infection was unchanged from the authors’ previous report.

RESULTS

A total of 4913 procedures were performed at 13 HCRN centers. The overall infection rate was 5.1%. Surgeons were compliant with all 5 steps of the protocol in 79.4% of procedures. The infection rate for the protocol alone was 8.1% and dropped to 4.9% when AICs were added. Multivariate analysis identified having ≥ 2 complex chronic conditions (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.26–2.44, p = 0.01) and a history of prior shunt surgery within 12 weeks (OR 1.84, 95% CI 1.37–2.47, p < 0.01) as independent risk factors for shunt infection. The use of AICs (OR 0.70, 95% CI 0.50–0.97, p = 0.05) and vancomycin irrigation (OR 0.36, 95% CI 0.21–0.62, p < 0.01) were identified as independent factors protective against shunt infection.

CONCLUSIONS

The authors report the third iteration of their quality improvement protocol to reduce the risk of shunt infection. Compliance with the protocol was high. These updated data suggest that the incorporation of AICs is an important, modifiable infection prevention measure. Vancomycin irrigation was also identified as a protective factor but requires further study to better understand its role in preventing shunt infection.

ABBREVIATIONS

AIC = antibiotic-impregnated catheter; CCC = complex chronic condition; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; IV = intravenous; QI = quality improvement.

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