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

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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).


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.


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.


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.

Article Information

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.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Diagram showing the HCRN shunt surgery protocol. In the step requiring the surgeon to ask for antibiotics, the surgeon requests that intravenous cefazolin (30 mg/kg) be given before making the first incision. In patients allergic to cephalosporins, vancomycin (15 mg/kg) is used. When the patient's hair is clipped, the hair is removed using clippers in the region of the incision as per the surgeon's usual practice. The shunt equipment selected for shunt insertion or revision is selected by the surgeon, except that antibiotic-impregnated shunts were not allowed. After the shunt procedure and prior to closure, 1 ml (10 mg/ml) of vancomycin mixed with 2 ml (2 mg/ml) of gentamicin is injected into the shunt reservoir with a 25-gauge needle (or smaller). In patients with a prior adverse reaction to vancomycin, the gentamicin is given alone. For this study, procedures in which vancomycin was not used were counted as noncompliant.

  • View in gallery

    Graph comparing mean monthly shunt infection rate before and after protocol implementation. The infection rate before implementation of the protocol (first 12 months) was 8.8% (dashed line); after implementation, it was 5.7% (solid line; chi-square = 8.93, p = 0.0028).



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