The shunt protocol developed by the Hydrocephalus Clinical Research Network (HCRN) was shown to significantly reduce shunt infections in children. However, its effectiveness had not been validated in a non-HCRN, small- to medium-volume pediatric neurosurgery center. The present study evaluated whether the 9-step Calgary Shunt Protocol, closely adapted from the HCRN shunt protocol, reduced shunt infections in children.
The Calgary Shunt Protocol was prospectively applied at Alberta Children’s Hospital from May 23, 2013, to all children undergoing any shunt procedure. The control cohort consisted of children undergoing shunt surgery between January 1, 2009, and the implementation of the Calgary Shunt Protocol. The primary outcome was the strict HCRN definition of shunt infection. Univariate analyses of the protocol, individual elements within, and known confounders were performed using Student t-test for measured variables and chi-square tests for categorical variables. Multivariable logistic regression was performed using stepwise analysis.
Two-hundred sixty-eight shunt procedures were performed. The median age of patients was 14 months (IQR 3–61), and 148 (55.2%) were male. There was a significant absolute risk reduction of 10.0% (95% CI 3.9%–15.9%) in shunt infections (12.7% vs 2.7%, p = 0.004) after implementation of the Calgary Shunt Protocol. In univariate analyses, chlorhexidine was associated with fewer shunt infections than iodine-based skin preparation solution (4.1% vs 12.3%, p = 0.02). Waiting ≥ 20 minutes between receiving preoperative antibiotics and skin incision was also associated with a reduction in shunt infection (4.5% vs 14.2%, p = 0.007). In the multivariable analysis, only the overall protocol independently reduced shunt infections (OR 0.19 [95% CI 0.06–0.67], p = 0.009), while age, etiology, procedure type, ventricular catheter type, skin preparation solution, and time from preoperative antibiotics to skin incision were not significant.
This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small- to medium-volume pediatric neurosurgery setting. Implementation of the Calgary Shunt Protocol independently reduced shunt infection risk. Chlorhexidine skin preparation and waiting ≥ 20 minutes between administration of preoperative antibiotic and skin incision may have contributed to the protocol’s quality improvement success.
ACH = Alberta Children’s Hospital; CSP = Calgary Shunt Protocol; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage.
ClassenDC, EvansRS, PestotnikSL, HornSD, MenloveRL, BurkeJP: The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med326:281–286, 199210.1056/NEJM1992013032605011728731)| false
DouglasA, UdyAA, WallisSC, JarrettP, StuartJ, Lassig-SmithM, et al.: Plasma and tissue pharmacokinetics of cefazolin in patients undergoing elective and semielective abdominal aortic aneurysm open repair surgery. Antimicrob Agents Chemother55:5238–5242, 2011
HaynesAB, WeiserTG, BerryWR, LipsitzSR, BreizatAH, DellingerEP, : A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med360:491–499, 200910.1056/NEJMsa0810119)| false
HurstEW: Adhesive arachnoiditis and vascular blockage caused by detergents and other chemical irritants: an experimental study. J Pathol Bacteriol70:167–178, 195510.1002/path.170070011513272131)| false
KestleJR, HolubkovR, Douglas CochraneD, KulkarniAV, LimbrickDDJr, LuerssenTG, et al.: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr17:391–396, 2016
KurzA, SesslerDI, LenhardtR: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med334:1209–1215, 199610.1056/NEJM1996050933419018606715)| false
LeeFH, PfefferM, Van HarkenDR, SmythRD, HottendorfGH: Comparative pharmacokinetics of ceforanide (BL-S786R) and cefazolin in laboratory animals and humans. Antimicrob Agents Chemother17:188–192, 198010.1128/AAC.17.2.1887387141)| false
PirotteBJ, LubansuA, BruneauM, LoqaC, Van CutsemN, BrotchiJ: Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst23:1251–1261, 2007
PirotteBJ, LubansuA, BruneauM, LoqaC, Van CutsemN, BrotchiJ: Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst23:1251–1261, 200710.1007/s00381-007-0415-517705062)| false
SimonTD, Riva-CambrinJ, SrivastavaR, BrattonSL, DeanJM, KestleJR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr1:131–137, 2008
SimonTD, Riva-CambrinJ, SrivastavaR, BrattonSL, DeanJM, KestleJR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr1:131–137, 200810.3171/PED/2008/1/2/13118352782)| false
SpaderHS, HertzlerDA, KestleJR, Riva-CambrinJ: Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr15:156–160, 2015
SpaderHS, HertzlerDA, KestleJR, Riva-CambrinJ: Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr15:156–160, 20152547957610.3171/2014.9.PEDS14215)| false