Letter: The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement.

Abstract

To the Editor: We read with great interest the article by Lakomkin et al1 on the role of prophylactic intraventricular antibiotics in pediatric patients undergoing shunt surgery. The authors have prospectively evaluated the role of prophylactic, intraoperative intraventricular antibiotic instillation in reducing need for secondary intervention to manage postoperative infections. Interestingly, this was even true with the use of antibiotic-impregnated (AI) catheters. We greatly appreciate the authors for their meaningful, valuable, and significant conclusions with the article. Infection is the most dreaded complication with shunt surgery. It is the most common cause of morbidity and additional intervention following ventriculoperitoneal shunt placement. In addition to the operative conditions, patient factors also have significant role in determining incidence and extent of infections. Shunt surgery entails the risk of infection because it requires the insertion of foreign materials which promote biofilm formation. Patient-related factors, like skin and subcutaneous tissue devitalization, with simple invasion of bacteria and accumulation of cerebrospinal fluid, blood, and exudates, are considered an excellent growth medium for bacteria. By washing out bacteria that come into contact with the surgical wound and the shunt material during the operation phase, saline irrigation may minimize contamination as well as wash out blood clots, and other devitalized tissues.2 Literature clearly supports that following standardized shunt operation protocols and the utilization of preoperative agendas do bring down shunt infection rates.3-5 A recent study by Raygor et al6 shows that use of intraventricular vancomycin brings down postoperative infections in shunt patients. Lee et al4 evaluated individual factors of surgical checklist used in shunt surgery to conclude that numerous individual treatment-level factors have been related with diminished shunt infection rates. It is conceivable that the low pace of shunt contamination shows the positive parts of the multistep surgical preparation, AI stitches, or different components.6 The preoperative patient hair washing with chlorhexidine cleanser has also been related with diminished shunt infection rates, similar to surgical preparation incorporating the use of alcohol, chlorhexidine, betadine, surgical solution, etc. Even the use of topical vancomycin has been reported to reduce shunt infection rates in pediatric patients.7 While analyzing the causes of multiple, frequent shunt failures, Rocque et al8 identified shunt failure clusters. They found that about 6% of children who were treated for hydrocephalus belonged shunt failure cluster. Shunt contamination, prematurity, and intraventricular hemorrhage showed higher connection with shunt failure cluster.8 In another clinical trial of patients with hydrocephalus undergoing ventriculoperitoneal shunt, 6% of those getting standard shunts, 2% of those accepting antibiotic shunts, and 6% of those accepting silver shunts had infections.9 In comparison to standard shunts, antibiotic shunts were related with an essentially lower frequency of infection, unlike silver shunts.9 Also, orderly surveys and meta-analyses10 did not locate any excellent proof to help the relative adequacy of antibiotic shunts at decreasing infection. Silver catheters have just been assessed for use in brief external ventricular drains, not permanently embedded shunts. When contamination is limited as a reason for shunt failure, noninfected revisions are more successive in patients with antibiotic shunts. This important work by Lakomkin et al1 is remarkable in being a prospective multicentric study specifically evaluating pediatric subgroup of patients. What is even more important is that this study underlines the importance of extra-precaution even with the use of AI shunts. It is reiterated that use of AI shunts should not prompt surgeons to lower their guard and concomitant use of intraventricular antibiotics should be done. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.