Calgary Shunt Protocol, an adaptation of the Hydrocephalus Clinical Research Network shunt protocol, reduces shunt infections in children

Restricted access

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

USD  $505.00

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

USD  $600.00

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS ACH = Alberta Children’s Hospital; CSP = Calgary Shunt Protocol; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage.
Article Information

Contributor Notes

Correspondence Jay Riva-Cambrin: University of Calgary and Alberta Children’s Hospital, Calgary, AB, Canada. jay.rivacambrin@ucalgary.ca.ACCOMPANYING EDITORIAL DOI: 10.3171/2018.11.PEDS18631.INCLUDE WHEN CITING Published online February 22, 2019; DOI: 10.3171/2018.10.PEDS18420.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
References
  • 1

    Brown EM: Antimicrobial prophylaxis in neurosurgery. J Antimicrob Chemother 31 (Suppl B):49631993

  • 2

    Choux MGenitori LLang DLena G: Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:8758801992

  • 3

    Classen DCEvans RSPestotnik SLHorn SDMenlove RLBurke JP: The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 326:2812861992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Darouiche ROWall MJ JrItani KMOtterson MFWebb ALCarrick MM: Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 362:18262010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Douglas AUdy AAWallis SCJarrett PStuart JLassig-Smith M: Plasma and tissue pharmacokinetics of cefazolin in patients undergoing elective and semielective abdominal aortic aneurysm open repair surgery. Antimicrob Agents Chemother 55:523852422011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Faillace WJ: A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Surg Neurol 43:3443501995

  • 7

    Haynes ABWeiser TGBerry WRLipsitz SRBreizat AHDellinger EP: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:4914992009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Henschen AOlson L: Chlorhexidine-induced degeneration of adrenergic nerves. Acta Neuropathol 63:18231984

  • 9

    Hurst EW: Adhesive arachnoiditis and vascular blockage caused by detergents and other chemical irritants: an experimental study. J Pathol Bacteriol 70:1671781955

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Kestle JDrake JMilner RSainte-Rose CCinalli GBoop F: Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg 33:2302362000

  • 11

    Kestle JRDrake JMCochrane DDMilner RWalker MLAbbott R III: Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg 98:2842902003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kestle JRGarton HJWhitehead WEDrake JMKulkarni AVCochrane DD: Management of shunt infections: a multicenter pilot study. J Neurosurg 105 (3 Suppl):1771812006

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kestle JRHolubkov RDouglas Cochrane DKulkarni AVLimbrick DD JrLuerssen TG: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 17:3913962016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    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. J Neurosurg Pediatr 8:22292011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

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

  • 16

    Kurz ASessler DILenhardt R: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 334:120912151996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Leaper DJEdmiston CE: World Health Organization: global guidelines for the prevention of surgical site infection. J Hosp Infect 95:1351362017

  • 18

    Lee FHPfeffer MVan Harken DRSmyth RDHottendorf GH: Comparative pharmacokinetics of ceforanide (BL-S786R) and cefazolin in laboratory animals and humans. Antimicrob Agents Chemother 17:1881921980

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Mangram AJHoran TCPearson MLSilver LCJarvis WR: Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 20:2502801999

  • 20

    Pirotte BJLubansu ABruneau MLoqa CVan Cutsem NBrotchi J: 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 Syst 23:125112612007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Riva-Cambrin JKestle JRHolubkov RButler JKulkarni AVDrake J: Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg Pediatr 17:3823902016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Rotim KMiklic PPaladino JMelada AMarcikic MScap M: Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 13:5845871997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Simon TDRiva-Cambrin JSrivastava RBratton SLDean JMKestle JR: Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr 1:1311372008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Spader HSHertzler DAKestle JRRiva-Cambrin J: 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 Pediatr 15:1561602015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sviggum HPJacob AKArendt KWMauermann MLHorlocker TTHebl JR: Neurologic complications after chlorhexidine antisepsis for spinal anesthesia. Reg Anesth Pain Med 37:1391442012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Todd MMHindman BJClarke WRTorner JC: Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 352:1351452005

  • 27

    Vinchon MDhellemmes P: Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:6926972006

  • 28

    Xu HHu FHu HSun WJiao WLi R: Antibiotic prophylaxis for shunt surgery of children: a systematic review. Childs Nerv Syst 32:2532582016

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 965 965 41
Full Text Views 167 167 9
PDF Downloads 142 142 9
EPUB Downloads 0 0 0
PubMed
Google Scholar