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Gilbert Cadena, Jean Wiedeman and James E. Boggan

: Rapidly growing nontuberculous mycobacteria cultured from home tap and shower water . Appl Environ Microbiol 76 : 6017 – 6019 , 2010 13 Viswanathan R , Bhagwati SN , Iyer V , Newalkar P : Ventriculoperitoneal shunt infection by mycobacterium fortuitum in an adult . Neurol India 52 : 393 – 394 , 2004

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Masanori Sato, Noriko Kubota, Yoshihiko Katsuyama, Yota Suzuki, Yosuke Miyairi, Kisei Minami and Masashi Kasai

a previously healthy adolescent . BMC Infect Dis 10 : 335 , 2010 14 Prusseit J , Simon M , von der Brelie C , Heep A , Molitor E , Völz S , : Epidemiology, prevention and management of ventriculoperitoneal shunt infections in children . Pediatr Neurosurg 45 : 325 – 336 , 2009 15 Simpkins CJ : Ventriculoperitoneal shunt infections in patients with hydrocephalus . Pediatr Nurs 31 : 457 – 462 , 2005 16 Valencia GB , Banzon F , Cummings M , McCormack WM , Glass L , Hammerschlag MR : Mycoplasma hominis and Ureaplasma

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Wajd N. Al-Holou, Thomas J. Wilson, Zarina S. Ali, Ryan P. Brennan, Kelly J. Bridges, Tannaz Guivatchian, Ghaith Habboub, Ajit A. Krishnaney, Giuseppe Lanzino, Kendall A. Snyder, Tracy M. Flanders, Khoi D. Than and Aditya S. Pandey

, Whiting A , Anderson EC , Witte S , Zanaty M , Tjoumakaris S , : Comparison of techniques for ventriculoperitoneal shunting in 523 patients with subarachnoid hemorrhage . J Neurosurg 121 : 904 – 907 , 2014 5 Choux M , Genitori L , Lang D , Lena G : Shunt implantation: reducing the incidence of shunt infection . J Neurosurg 77 : 875 – 880 , 1992 6 Giannetti AV , Pimenta FG , Clemente WT : Does the simultaneous use of a neuroendoscope influence the incidence of ventriculoperitoneal shunt infection? World Neurosurg 98 : 171

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Naomi Ochieng', Humphrey Okechi, Susan Ferson and A. Leland Albright

Palliative Care Chronic Ventriculitis Growth of Other Pathogen Total Staphylococcus aureus 5 5 0 2 1 0 13 Other Staphylococcus spp 2 9 0 1 0 0 12 Gram-negative bacilli 5 6 1 5 1 3 21 Streptococcus spp 1 1 1 0 0 0 3 Mixed infection 0 1 0 1 0 0 2 Total 13 22 2 9 2 3 51 Discussion Ventriculoperitoneal shunt infections are a major cause of morbidity and mortality in children requiring CSF diversion. Our study comprised a young population, ranging in age

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Luis M. Tumialán, Franklin Lin and Sanjay K. Gupta

: Ventriculoperitoneal shunt infection due to Serratia marcescens . J Infect 50 : 138 – 141 , 2005 6 Byard R , Koszyca B , Qiao M : Unexpected childhood death due to a rare complication of ventriculoperitoneal shunting . Am J Forensic Med Pathol 22 : 207 – 210 , 2001 7 Curtis C , Chock S , Henderson T , Holman MJ : A fatal case of necrotizing fasciitis caused by Serratia marcescens . Am Surg 71 : 228 – 230 , 2005 8 Garcia-Tsao G : Spontaneous bacterial peritonitis . Gastroenterol Clin North Am 21 : 257 – 275 , 1992 9 Gaskill SJ

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Farideh Nejat, Parvin Tajik, Syed Mohammad Ghodsi, Banafsheh Golestan, Reza Majdzadeh, Shahrooz Yazdani, Saeed Ansari, Majid Dadmehr, Sara Ganji, Mehri Najafi, Fatemeh Farahmand and Farzaneh Moatamed

Object

Previous studies have shown nutritional benefits of breastfeeding for a child's health, especially for protection against infection. Protective factors in human milk locally and systemically prevent infections in the gastrointestinal as well as upper and lower respiratory tracts. It remains unclear whether breastfeeding protects infants against ventriculoperitoneal (VP) shunt infection.

Methods

A cohort study was conducted from December 2003 to December 2006 at Children's Hospital Medical Center in Tehran, Iran. A total of 127 infants with hydrocephalus who were treated using a VP shunt in the first 6 months of life were enrolled. Each infant's breastfeeding method was classified as either exclusively breastfed (EBF), combination feedings of breast milk and formula (CFBF), or exclusively formula-fed (EFF). Infants were followed up to determine the occurrence of shunt infection within 6 months after operation. Statistical analysis was performed using survival methods.

Results

Infants ranged in age from 4 to 170 days at the time of shunt insertion (mean 69.6 days), and 57% were males. Regarding the breastfeeding categories, 57.5% were EBF, 25.2% were CFBF, and 17.3% were EFF. During the follow-up, shunt infection occurred in 16 patients, within 15 to 173 days after shunt surgery (median 49 days). The 6-month risk of shunt infection was 8.5% (95% confidence interval [CI] 4–18%) in the EBF group, 16.5% (95% CI 7–35%) in the CFBF group, and 26.0% (95% CI 12–52%) in the EFF group. There was no statistically significant difference between these 3 groups (p = 0.11). The trend test showed a significant trend between the extent of breastfeeding and the risk of shunt infection (p = 0.035), which persisted even after adjustment for potential confounding variables (hazard ratio = 2.01, 95% CI 1.01–4).

Conclusions

This study supports the protective effect of breastfeeding against shunt infection during the first 6 months of life and the presence of a dose–response relationship, such that the higher the proportion of an infant's feeding that comes from human milk, the lower the incidence of shunt infection. Encouraging mothers of infants with VP shunts to breastfeed exclusively in the first 6 months of life is recommended.

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William B. Lo, Mitul Patel, Guirish A. Solanki and Anthony Richard Walsh

Gemella haemolysans has long been considered a commensal in the human upper respiratory tract. Commensals are natural inhabitants on or within another organism, deriving benefit without harming or benefiting the host. Opportunistic infection of the CNS by the species is exceedingly rare. In the present case, a 16-year-old boy was admitted with a ventriculoperitoneal shunt infection, which was confirmed to be due to G. haemolysans. Following antibiotic treatment, removal of the old shunt, and delayed insertion of a new shunt, the patient made a full neurological recovery. To the authors' knowledge, this is the eighth case of CNS infection with G. haemolysans. Although prosthesis-related infections have been reported in other systems, this is the first case of CNS infection by the bacterium associated with an implant. Previous reported cases of CNS infection by G. haemolysans are reviewed. Due to the variable Gram staining property of the organism, the difficulty in diagnosing G. haemolysans infection is emphasized.

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John R. W. Kestle, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, William E. Whitehead, Marion L. Walker, W. Jerry Oakes, James M. Drake, Thomas G. Luerssen, Tamara D. Simon and Richard Holubkov

Object

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).

Methods

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.

Results

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.

Conclusions

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.

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E. Andrew Stevens, Elizabeth Palavecino, Robert J. Sherertz, Zakariya Shihabi and Daniel E. Couture

Object

Treatment of ventriculoperitoneal shunt infections frequently requires placement of an external ventricular drain (EVD). Surveillance specimens obtained from antibiotic-impregnated (AI) EVDs may be less likely to demonstrate bacterial growth, potentially resulting in undertreatment of an infection. The purpose of this study was to assess whether AI EVDs had any significant effect on bacterial culture results compared with nonantibiotic-impregnated (NAI) EVDs.

Methods

In vitro assays were performed using AI EVDs containing minocycline and rifampin (VentriClear II, Medtronic) and NAI EVD controls (Bioglide, Medtronic). The presence of antibiotics was evaluated via capillary electrophoresis of sterile saline drawn from AI and NAI EVDs after predefined incubation intervals. Antimicrobial activity was assessed by evaluating zones of inhibition created by the catheter aspirates on plates inoculated with a quality control strain of Staphylococcus epidermidis (American Type Culture Collection strain 12228). To determine the effects of cultures drawn through AI compared with NAI EVDs, the quality control strain was then incubated within 4 new AI and 4 new NAI EVDs for predefined intervals before being plated on culture media. Spread and streak plate culture results from each type of catheter were compared at each time interval.

Results

Capillary electrophoresis showed that more minocycline than rifampin was eluted from the AI EVDs. Sterile saline samples incubated within the AI EVDs demonstrated zones of growth inhibition when placed on plates of S. epidermidis at all time intervals tested. No zones of inhibition were noted on NAI EVD control plates. When a standardized inoculum of S. epidermidis was drawn through AI and NAI EVDs, antimicrobial effects were observed after incubation in the AI EVD group only. Colony counting demonstrated that significantly fewer colonies resulted from samples drawn through AI compared with NAI EVDs at the multiple time intervals. Similarly, streak plating yielded a statistically significant number of false-negative results from AI compared with NAI EVDs at 2 time intervals.

Conclusions

The findings in the current study indicate that the risk of a false-negative culture result may be increased when a CSF sample is drawn through an AI catheter. In the management of a known shunt infection, a false-negative result from an EVD culture specimen may lead to an inappropriately short duration of antibiotic therapy. These data have significant clinical implications, particularly given the widespread use of AI drains and the current high rates of shunt reinfection after EVD use worldwide.

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.36.3.2 Abstract Tuesday's Abstracts Paper 13: Ventriculoperitoneal Shunt Infection Rates: Implementation of a Uniform Protocol and Evaluation of Outcomes Eric R. Trumble , M.D. , Matt P. Diehl