Abstract
BackgroundVentriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI.MethodsRelevant studies were identified from MEDLINE and EMBASE and from reference searching of included studies and recent review articles on relevant topics. The Newcastle-Ottawa Scale was used to assess quality and risk of bias. A random effects model was used to pool individual study estimates and 95% confidence intervals (CI) were calculated using the exact Poisson method. Heterogeneity was assessed using the heterogeneity χ2 and I-squared tests. Subgroup analyses were performed and a funnel plot constructed to assess publication bias.ResultsThere were a total of 35 studies which yielded 752 infections from 66,706 catheter-days of observation. The overall pooled incidence rate of VAI was 11.4 per 1000 catheter days (95% CI 9.3 to 13.5), for high quality studies the rate was 10.6 (95% CI 8.3 to 13) and 13.5 (95% CI 8.9 to 18.1) for low quality studies. Studies which had mean duration of EVD treatment of less than 7 days had a pooled VAI rate of 19.6 per 1000 catheter-days, those with mean duration of 7–10 days had VAI rate of 12.8 per 1000 catheter-days and those with mean duration greater than 10 days had VAI rate of 8 per 1000 catheter-days. There was significant heterogeneity for the primary outcome (p = 0.004, I-squared = 44%) and most subgroups. The funnel plot did not show evidence for publication bias.ConclusionsThe incidence rate of VAI is 11.4 per 1000 catheter-days. Further research should focus on analysis of risk factors for VAI and techniques for reducing the rate of VAI.
Highlights
Ventriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality
antibiotic-impregnated catheters (AIC) were used in four studies (33% to 100% of patients) and were not used in 18 with AIC information unavailable in the remaining 13
There was, significant heterogeneity for the pooled result (p = 0.004, I-squared = 44%) and most subgroup analyses. The reasons for this heterogeneity are numerous and include variations in definition of VAI, antibiotic usage, cerebrospinal fluid (CSF) investigation regimes, patient population, publication year, duration of ventriculostomy insertion, type of catheter, length of subcutaneous tunnel and potentially other unknown factors that cannot be addressed in this meta-analysis
Summary
Ventriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI. There are various clinical dilemmas faced by physicians caring for patients with ventriculostomies with regard to prompt diagnosis, investigation and treatment of VAI Clinical signs such as fever, altered consciousness, nuchal rigidity, emesis and focal neurological deficits are severely confounded by the primary neurological insult, treatments directed at preventing secondary neurological injury (sedation, neuromuscular blockade), seizures, electrolyte disturbances and non-neurological. These difficulties are reflected in the lack of consensus definition for VAI, uncertainty regarding the trigger for empirical antibiotic therapy and the resultant wide variations in practice relating to both
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