Recurrent cerebrospinal fluid shunt infection and the efficacy of reusing infected ventricular entry sites

Clinical article

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Object

The objective of this investigation was to review the clinical characteristics of recurrent CSF shunt infections in a large pediatric neurosurgical practice and to assess the safety and efficacy of reusing original ventricular entry sites for external ventricular drainage during treatment of infections and for subsequent reinsertion of shunts.

Methods

Prospectively accrued clinical data on all patients treated at Children's Hospital Colorado for CSF shunt infections within a 10.5-year span were retrospectively investigated.

Results

One hundred twenty-one consecutive cases of CSF shunt infection met inclusion criteria. Recurrent shunt infection attributable to the management of these infections occurred in 14 cases (11.6%). Three recurrent infections were with their original organisms, 7 were organisms different from the original organisms, and 4 were indeterminate.

Conclusions

Half or more of recurrent shunt infections were with organisms different from the original organism, and hence were new-type infections introduced during the management of the original infections. Incomplete eradication of original pathogens accounted for 3 (21.4%) of the 14 recurrent infections. Reusing recently infected or contaminated ventricular entry sites, both for CSF drainage during treatment and for implantation of new shunts, was as safe, with regard to risk of recurrent infection, as switching to new entry sites. Prior evidence of shunt infection is not, alone, a sufficient reason to change to a previously well-functioning site, and reuse of contaminated ventricular entry sites avoids all risks associated with making new ventricular entries.

Article Information

Address correspondence to: Ken R. Winston, M.D., 12631 East 17th Avenue, Aurora, Colorado 80045. email: krwinston@gmail.com.

Please include this information when citing this paper: published online April 19, 2013; DOI: 10.3171/2013.3.PEDS12478.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Anderson RCKan PKlimo PBrockmeyer DLWalker MLKestle JR: Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg 101:1 Suppl53582004

2

Arnell KEnblad PWester TSjölin J: Treatment of cerebrospinal fluid shunt infections in children using systemic and intraventricular antibiotic therapy in combination with externalization of the ventricular catheter: efficacy in 34 consecutively treated infections. J Neurosurg 107:3 Suppl2132192007

3

Bayston RLeung TSWilkins BMHodges B: Bacteriological examination of removed cerebrospinal fluid shunts. J Clin Pathol 36:9879901983

4

Bourgeois MSainte-Rose CCinalli GMaixner WMalucci CZerah M: Epilepsy in children with shunted hydrocephalus. J Neurosurg 90:2742811999

5

Campbell JWShunt infections. Albright ALPollack IFAdelson PD: Principals and Practice of Pediatric Neurosurgery ed 2New YorkThieme2008. 11411147

6

Centers for Disease Control and Prevention: Surgical Site Infection (SSI) Event (http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf) [Accessed March 20 2013]

7

Clemmensen DRasmussen MMMosdal C: A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics. Childs Nerv Syst 26:151715212010

8

Enger Svendsen FWester K: CSF shunt infections in children: experiences from a population-based strudy. Acta Neurochir (Wien) 154:2432482003

9

Gold MMShifteh KValdberg SLombard JLipton ML: Brain injury due to ventricular shunt placement delineated by diffusion tensor imaging (DTI) tractography. Neurologist 14:2522542008

10

Gutiérrez-González RBoto GRFernández-Pérez CPrado González ND: [Risk factors for cerebrospinal fluid shunt infection.]. Med Clin (Barc) 136:4174222011. (Span)

11

Hayhurst CCooke RWilliams DKandasamy JO'Brien DFMallucci CL: The impact of antibiotic-impregnated catheters on shunt infection in children and neonates. Childs Nerv Syst 24:5575622008

12

Ines DFMarkand ON: Epileptic seizures and abnormal electroencephalographic findings in hydrocephalus and their relation to the shunting procedures. Electroencephalogr Clin Neurophysiol 42:7617681977

13

Jeelani NUKulkarni AVDesilva PThompson DNHayward RD: Postoperative cerebrospinal fluid wound leakage as a predictor of shunt infection: a prospective analysis of 205 cases. Clinical article. J Neurosurg Pediatr 4:1661692009

14

Kan PKestle J: Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst 23:7737772007

15

Kestle JRGarton HJWhitehead WEDrake JMKulkarni AVCochrane DD: Management of shunt infections: a multicenter pilot study. J Neurosurg 105:3 Suppl1771812006

16

Kestle JRRiva-Cambrin JWellons JC IIIKulkarni AVWhitehead WEWalker ML: A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. Clinical article. J Neurosurg Pediatr 8:22292011

17

Klepper JBüsse MStrassburg HMSörensen N: Epilepsy in shunt-treated hydrocephalus. Dev Med Child Neurol 40:7317361998

18

Kobayashi OIwasaki YYamanouchi HSugai K: [A case of refractory status epilepticus associated with aberrant intracranial shunt tube: efficacy of lidocaine in the determination of the epileptic focus.]. No To Hattatsu 26:3293341994. (Jpn)

19

Kulkarni AVDrake JMLamberti-Pasculli M: Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:1952012001

20

Kulkarni AVRabin DLamberti-Pasculli MDrake JM: Repeat cerebrospinal fluid shunt infection in children. Pediatr Neurosurg 35:66712001

21

Liguori GAbate MBuono SPittore L: EEG findings in shunted hydrocephalic patients with epileptic seizures. Ital J Neurol Sci 7:2432471986

22

Malhotra ABell WEHenderson FWInfections of the central nervous system. David RB: Clinical Pediatric Neurology ed 3New YorkDemos Medical Publishing2009. 211236

23

Maniker AHVaynman AYKarimi RJSabit AOHolland B: Hemorrhagic complications of external ventricular drainage. Neurosurgery 59:4 Suppl 2ONS419ONS4252006

24

Ngo QNRanger ASingh RNKornecki ASeabrook JAFraser DD: External ventricular drains in pediatric patients. Pediatr Crit Care Med 10:3463512009

25

Pattavilakom AXenos CBradfield ODanks RA: Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J Clin Neurosci 14:5265312007

26

Ragel BTBrowd SRSchmidt RH: Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:2422472006

27

Ralph KMoylan PCanady ASimmons S: The effects of multiple shunt revisions on neuropsychological functioning and memory. Neurol Res 22:1311362000

28

Rammos SKlopfenstein JAugsburger LWang HWagenbach APoston J: Conversion of external ventricular drains to ventriculoperitoneal shunts after aneurysmal subarachnoid hemorrhage: effects of site and protein/red blood cell counts on shunt infection and malfunction. Clinical article. J Neurosurg 109:100110042008

29

Ritz RRoser FMorgalla MDietz KTatagiba MWill BE: Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients. BMC Infect Dis 7:382007

30

Saladino AWhite JBWijdicks EFLanzino G: Malplacement of ventricular catheters by neurosurgeons: a single institution experience. Neurocrit Care 10:2482522009

31

Sciubba DMMcGirt MJWoodworth GFCarson BJallo GI: Prolonged exposure to antibiotic-impregnated shunt catheters does not increase incidence of late shunt infections. Childs Nerv Syst 23:8678712007

32

Simon TDHall MDean JMKestle JRRiva-Cambrin J: Reinfection following initial cerebrospinal fluid shunt infection. Clinical article. J Neurosurg Pediatr 6:2772852010

33

Simon TDHall MRiva-Cambrin JAlbert JEJeffries HELafleur B: Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:1561652009

34

Simon TDWhitlock KBRiva-Cambrin JKestle JRRosenfeld MDean JM: Revision surgeries are associated with significant increased risk of subsequent cerebrospinal fluid shunt infection. Pediatr Infect Dis J 31:5515562012

35

Snedecor GWCochran WG: Sampling from the binomial distribution. Statistical Methods ed 6Ames, IowaIowa State University Press1976. 199226

36

Thompson DNHartley JCHayward RD: Shunt infection: is there a near-miss scenario?. J Neurosurg 106:1 Suppl15192007

37

Tubbs RSBanks JTSoleau SSmyth MDWellons JC IIIBlount JP: Complications of ventriculosubgaleal shunts in infants and children. Childs Nerv Syst 21:48512005

38

Varfis GBerney JBeaumanoir A: Electro-clinical follow-up of shunted hydrocephalic children. Childs Brain 3:1291391977

39

Wang KWChang WNShih TYHuang CRTsai NWChang CS: Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis 57:44482004

40

Winston KRBhardwaj V: Reuse of ventricular drain sites for cerebrospinal fluid shunting in patients with no prior infection. Clinical article. J Neurosurg Pediatr 5:4494532010

41

Winston KRDolan SA: Multidisciplinary approach to cerebrospinal fluid shunt infection with an appeal for attention to details in assessment and standardization in reporting. Clinical article. J Neurosurg Pediatr 7:4524612011

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