Abstract
PurposeShunt infection is a major problem in paediatric neurosurgery. Our institution introduced a mandatory shunt protocol with the aim of reducing infection rate.MethodsA retrospective cohort study including consecutive patients undergoing permanent shunt operations (primary insertion and revision) across two study periods: 3 years immediately prior (2009–2012) and 3 years immediately after (2012–2015) protocol introduction. Absolute and relative risk reductions (ARR/RRR) and Chi-square statistical analysis was used alongside logistic regression, where any single factor with p ≤ 0.20 included in the multivariate model, producing an odds ratio (OR).ResultsEight hundred nine operations in 504 children were identified (442 pre-protocol, 367 post). Overall infection rate decreased from 5.43% (24/442) pre-protocol to 3.27% (12/367) post-protocol (ARR = 2.16%, RRR = 39.8%, NNT = 46.3, p = 0.138), which did not reach statistical significance. For primary shunt insertions, infection rate reduced from 3.63 to 2.55% (ARR = 1.08%, RRR = 29.8%, NNT = 92.6, p = 0.565), whilst for revisions, it reduced from 6.83 to 3.81% (ARR = 3.02%, RRR 44.2%, NNT = 33.1, p = 0.156). Multivariate logistic regression showed that surgeon experience was a statistically significant predictor of infection, whilst responsible pathogens and latency were similar across the pre- and post-protocol groups.ConclusionThe protocol reduced overall infection rate in primary and revision shunt operations and we recommend paediatric units consider introducing a similar protocol for these procedures.
Highlights
Implanted CSF shunts are used extensively in the management of hydrocephalus, and shunt-associated infection is a major source of morbidity in paediatric neurosurgical practice [1]
BRevision^ was defined as any surgery on a child with a pre-existing, internal CSF shunt whereby one or more of the components of the shunt were changed, but that the child continued to have a permanent, internalised shunt at the end of the procedure
Eight hundred nine procedures performed in 504 patients matched our inclusion criteria, with 442 procedures in the pre-protocol cohort and 367 in the post-protocol cohort
Summary
Implanted CSF shunts are used extensively in the management of hydrocephalus, and shunt-associated infection is a major source of morbidity in paediatric neurosurgical practice [1]. Single-centre shunt infection rates range between 6 and 15% [2, 3]. A recent multi-centre study, which included 1036 patients from 6 centres in the USA, reported an overall shunt surgery infection rate of 11% [4]. Shunt infection is associated with considerable mortality and morbidity. Infection-related mortality has been reported to range from 1.5 to 22% [2], with those surviving facing the risk of significant morbidities such as permanent neurological deficit, cognitive impairment, and epilepsy [5]. Shunt infections are treated with intravenous and intra-ventricular antibiotics, which come with associated side effects, lengthy hospital stays, and the need for additional surgical procedures [6]
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