Antibiotic-impregnated Catheters Research Articles

Abstract TP306: Impact of Medical Complications on Outcome Following Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) results in significant mortality and morbidity, half of which occurs in the first 6 hours. Patients surviving beyond the initial trauma are prone to medical complications during their stay in the neurological ICU (NICU). Prior studies have demonstrated increased mortality and morbidity in SAH and ischemic stroke related to medical complications. Here we report the major complications that occur during the acute care of ICH patients and how those complications impact outcome. Methods: Patients presenting with CT-identified ICH admitted to the NICU between 2009 and 2012 were prospectively enrolled in the Columbia Intra-Cerebral Hemorrhage Outcomes Project. All medical complications were identified prospectively by the NICU attending physician and adjudicated by a panel of neurologists and neurosurgeons. The modified Rankin Scale (mRS) was used to evaluate neurologic function at 3 months. Univariate analysis and stepwise logistic regression were used to identify predictors of poor 3-month outcome (mRS >3). All outcome measures were corrected for admission demographics and severity of presentation. Results: Out of 222 patients, 182 (81.9%) suffered from a medical complication. The mean number of complications was 1.92 (range 0-8). The most common complications were hyperglycemia (39.6%), pneumonia (26.6%), hyponatremia (24.8%), fever greater than 39.2% (19.4%), and catheter- associated urinary tract infection (UTI) (15.8%). Of the 164 surviving patients, 120 (73.2%) had available follow-up at 3 months. The mean follow-up mRS was 3.28. Multivariate analysis demonstrated an OR for poor outcome of 6.41 (1.33-48.16) with pneumonia, 8.05 (2.01-38.45) with UTI, and 12.99 (1.62-146.24) for acute renal failure. Conclusions: Medical complications are prevalent among ICH patients in the NICU. Protection against urological and respiratory diseases provides a reasonable target of morbidity reduction amongst ICH patients. Aggressive sterile procedure, frequent respiratory therapy, vigilant assessment of aspiration risk, and the use of antibiotic-impregnated catheters may reduce disease burden.

Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution

Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated. A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period. At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation. Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

Types of indwelling urinary catheters for long-term bladder drainage in adults

Prolonged urinary catheterization is common amongst people in long-term care settings and this carries a high risk of developing a catheter-related urinary tract infection and associated complications. A variety of different kinds of urethral catheters are available. Some have been developed specifically to lower the risk of catheter-associated infection, for example antiseptic or antibiotic impregnated catheters. Ease of use, comfort and handling for the caregivers and patients, and cost-effectiveness are also important factors influencing choice. The primary objective was to determine which type of indwelling urinary catheter is best to use for long-term bladder drainage in adults. We searched the Cochrane Incontinence Group Specialised Register (last searched 31 March 2011), which includes searches of CENTRAL, MEDLINE and handsearching of journals and conference proceedings, and the reference lists of relevant articles. All randomised trials comparing types of indwelling urinary catheters for long-term catheterization in adults. Long-term catheterization was defined as more than 30 days. Data extraction has been undertaken by two review authors working independently and simultaneously. Any disagreement has been resolved by a third review author. The included trial data were handled according to the methods of the Cochrane Handbook for Systematic Reviews of Interventions. Three trials were included, involving 102 adults in various settings. Two trials had a parallel group design and one was a randomised cross-over trial.Only two of the six targeted comparisons were assessed by these trials: antiseptic impregnated catheters versus standard catheters (one trial) and one type of standard catheter versus another standard catheter (two trials).The single small cross-over trial was inadequate to assess the value of silver alloy (antiseptic) impregnated catheters. In the two trials comparing different types of standard catheters, estimates of differences were all imprecise because the trials also had small sample sizes; confidence intervals (CI) were too wide to rule out clinically important differences. One trial did suggest, however, that the use of a hydrogel coated latex catheter rather than a silicone catheter may be better tolerated (risk ratio (RR) for need for early removal 0.41, 95% CI 0.22 to 0.77). The updated search could not reveal any additional evidence. Very few trials have compared different types of catheter for long-term bladder drainage. All trials were small and showed methodological weaknesses. Therefore, the evidence was not sufficient as a reliable basis for practical conclusions. Further, better quality trials are needed to address the current lack of evidence in this clinically important area.

Antibiotic impregnated catheter coverage of deep brain stimulation leads facilitates lead preservation after hardware infection

Deep brain stimulation (DBS) has become a reliable and effective treatment for many disorders. However, the risk of long-term hardware-related complications is notable, and most concerning is hardware-related infections. Given the risk of hardware removal in the setting of infection, we retrospectively examined the implementation of a novel technique using antibiotic covered catheter protection of DBS leads after infection. The effect on hardware salvage and ease of reimplantation of the DBS extension and implantable pulse generator (IPG) was examined. A total of nine (9%) out of 100 DBS patients met the inclusion criteria with 11 DBS hardware-related infections at either the frontal, parietal, or IPG sites, from June 2003 to November 2010, at our institution. Subsequent to the initial patient in the series, a total of eight patients had placement of a short segment (approx. 4cm long) of antibiotic impregnated catheter (Bactiseal, Codman, Johnson & Johnson, Raynham, MA, USA) over the distal end of the DBS leads at the parietal incision. Seven of these eight patients presented with pus and deep tissue infections around the hardware at either the frontal, parietal, or chest incisions. In seven of these eight patients (87.5%) we were able to protect and salvage their DBS leads without need for removal. In conclusion, this novel technique provides a simple reimplantation operation, with a decreased risk of DBS lead damage. It may improve the preservation of DBS leads when hardware infection occurs, is inexpensive, and confers no additional risks to patients.

A Randomized, Controlled Trial of Catheter-Related Infectious Event Rates Using Antibiotic-Impregnated Catheters Versus Conventional Catheters in Pediatric Cardiovascular Surgery Patients.

: We conducted a randomized, controlled clinical trial to determine whether a difference in catheter-associated blood stream infection (CABSI) incidence existed between children who underwent cardiac surgery and had a central venous catheter impregnated with minocycline and rifampin versus those who had a conventional, nonimpregnated catheter after cardiac surgery. Due to a lower number of infections than expected, the study was terminated early. Among 288 evaluable patients, the rates of CABSI and line-related complications were similar between the 2 groups.

Comparison of Infection Rate With the Use of Antibiotic-Impregnated vs Standard Extraventricular Drainage Devices

External ventricular drainage (EVD) catheters provide reliable and accurate means of monitoring intracranial pressure and alleviating elevated pressures via drainage of cerebrospinal fluid (CSF). CSF infections occur in approximately 9% of patients. Antibiotic-impregnated (AI) EVD catheters were developed with the goal of reducing the occurrence of EVD catheter-related CSF infections and their associated complications. To present an international, prospective, randomized, open-label trial to evaluate infection incidence of AI vs standard EVD catheters. Infection was defined as (1) proven infection, positive CSF culture and positive Gram stain or (2) suspected infection: (A) positive CSF culture with no organisms identified on initial Gram stain; (B) negative CSF culture with a gram-positive or -negative stain; (C) CSF leukocytosis with a white blood cell/red blood cell count >0.02. Four hundred thirty-four patients underwent implantation of an EVD catheter. One hundred seventy-six patients in the AI-EVD cohort and 181 in the standard EVD catheter cohort were eligible for evaluation of infection. The 2 groups were similar in all clinical characteristics. Proven infection was documented in 9 (2.5%) patients (AI: 4 [2.3%] vs standard: 5 [2.8%], P = 1.0). Suspected infection was documented in 31 (17.6%) patients receiving AI and 37 (20.4%) patients receiving standard EVD catheters, P = .504. Duration of time to suspected infection was prolonged in the AI cohort (8.8 ± 6.1 days) compared with the standard EVD cohort (4.6 ± 4.2 days), P = .002. AI-EVD catheters were associated with an extremely low rate of catheter-related infections. AI catheters were not associated with risk reduction in EVD infection compared to standard catheters. Use of AI-EVD catheters is a safe option for a wide variety of patients requiring CSF drainage and monitoring, but the efficacy of AI-EVD catheters was not supported in this trial.

Impact of antibiotic-impregnated catheters on the timing of cerebrospinal fluid infections in non-traumatic subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) has been recognized as a risk factor for ventriculostomy-related infections (VRI). In addition to the hemorrhagic cerebrospinal fluid (CSF), the potential need for prolonged catheterization may contribute to the increased CSF infection rate in this population. The use of antibiotic-impregnated catheters (AIC) has effectively reduced the risk of VRI. Herein, we examined specifically the impact of systematic insertion of AIC on the timing of CSF infections in SAH patients. Retrospective review of patients admitted between April 2006 to March 2009 with a non-traumatic SAH who required an external ventriculostomy. Only patients with AIC were included. A meningitis or ventriculitis was diagnosed according to the published criteria of the Center for Disease Control and Prevention. This study includes 75 patients in which 97 drains were inserted. Seven infections (7/75 = 9.3%) occurred over 1,024 drainage days (DD), resulting in a rate of 6.8 infections/1,000 DD. The mean drainage time was 15.4 days in the infected AIC group compared with 10.2 days in the non-infected AIC group. No infection occurred before day 9 of drainage and 71% (5/7) occurred after more than 2 weeks of drainage. The observed timing of infections is delayed in comparison with that reported in series using non-AIC, which typically occur prior to the 10th day of drainage. In the high-risk population of non-traumatic SAH, the use of AIC delays the occurrence of infection compared with that reported with non-antibiotic-impregnated catheters. This may orient management strategies in SAH patients requiring a ventriculostomy.

How to deal with dialysis catheters in the ICU setting

Acute kidney insufficiency (AKI) occurs frequently in intensive care units (ICU). In the management of vascular access for renal replacement therapy (RRT), several factors need to be taken into consideration to achieve an optimal RRT dose and to limit complications. In the medium and long term, some individuals may become chronic dialysis patients and so preserving the vascular network is of major importance. Few studies have focused on the use of dialysis catheters (DC) in ICUs, and clinical practice is driven by the knowledge and management of long-term dialysis catheter in chronic dialysis patients and of central venous catheter in ICU patients. This review describes the appropriate use and management of DCs required to obtain an accurate RRT dose and to reduce mechanical and infectious complications in the ICU setting. To deliver the best RRT dose, the length and diameter of the catheter need to be sufficient. In patients on intermittent hemodialysis, the right internal jugular insertion is associated with a higher delivered dialysis dose if the prescribed extracorporeal blood flow is higher than 200 ml/min. To prevent DC colonization, the physician has to be vigilant for the jugular position when BMI < 24 and the femoral position when BMI > 28. Subclavian sites should be excluded. Ultrasound guidance should be used especially in jugular sites. Antibiotic-impregnated dialysis catheters and antibiotic locks are not recommended in routine practice. The efficacy of ethanol and citrate locks has yet to be demonstrated. Hygiene procedures must be respected during DC insertion and manipulation.

Catéteres impregnados con antibiótico. Una herramienta útil frente a la infección

Progress in the treatment of hydrocephalus and particularly of cerebrospinal fluid (CSF) diversion surgery has been continuous and significant from cranial bandaging, which was one of the initial hydrocephalus treatments in the 16th century, to last-generation CSF shunts. However, infection currently remains the most frequent and serious complication despite the efforts made to prevent it. One of these current prevention measures is the use of antibiotic-impregnated catheters. A retrospective cohort study including shunts and external ventricular drains was designed to assess their efficacy in our scenario. The results show that rifampicin- and clindamycin-impregnated catheters are a helpful tool against CSF shunt-derived infection.

Progression of cerebrospinal fluid cell count and differential over a treatment course of shunt infection

The physiological reaction of CSF white blood cells (WBCs) over the course of treating a shunt infection is undefined. The authors speculated that the CSF WBC count varies with different infecting organisms in peak level and differential percentage of polymorphonuclear (PMN) leukocytes, lymphocytes, monocytes, and eosinophils. The authors hope to identify clinically useful trends in the progression of CSF WBCs by analyzing a large group of patients with successfully treated shunt infections. The authors reviewed 105 successfully treated cases of shunt infections at Riley Hospital for Children. The study dates ranged from 2000 to 2004; this represented a period prior to the routine use of antibiotic-impregnated shunt catheters. They analyzed the following organisms: coagulase-negative staphylococci, Staphylococcus aureus, Propionibacterium acnes, Streptococcal species, and gram-negative organisms. The initial CSF sample at diagnosis was analyzed, as were levels over 14 days of treatment. Model fitting was performed to generate curves for the expected progression of the WBC counts and the differential PMN leukocytes, lymphocyte, monocyte, and eosinophil percentages. Gram-negative organisms resulted in a higher initial (p = 0.03) and peak WBC count with a greater differential of PMN leukocytes compared with other organisms. Propionibacterium acnes infections were associated with a significantly lower WBC count and PMN leukocytes percentage (p = 0.02) and higher eosinophil percentage (p = 0.002) than other organisms. The pattern progression of the CSF WBC count and differential percentages was consistent for all infections. There was an initial predominance of PMN leukocytes, followed by a delayed peak of lymphocytes, monocytes, and eosinophils over a 14-day course. All values trended toward zero over the treatment course. The initial and peak levels of CSF WBCs vary with the infecting organisms. The CSF cell counts showed a predictable pattern during the treatment of shunt infection. These trends may be useful to the physician in clinical decision making, although there is a wide range of variability.

Improved Antibiotic-Impregnated Catheters with Extended-Spectrum Activity against Resistant Bacteria and Fungi

Minocycline-rifampin-impregnated central venous catheters (M/R CVCs) have been shown to be efficacious in reducing catheter-related bloodstream infections (CRBSI) and inhibiting the biofilm adherence of resistant Gram-positive and Gram-negative pathogens, with the exception of Pseudomonas aeruginosa and Candida spp. To expand the spectrum of antimicrobial activity, a novel second-generation M/R catheter was developed by adding chlorhexidine (CHX-M/R). CVCs and peripherally inserted central catheters (PICCs) were impregnated with CHX-M/R and compared with first-generation M/R catheters, CHX-silver sulfadiazine-treated CVCs (CHX/SS-CVCs), chlorhexidine-treated PICCs, and uncoated catheters. A biofilm catheter colonization model was used to assess the efficacy of catheters against methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecium (VRE), P. aeruginosa, Candida albicans, and Candida glabrata. CHX-M/R-impregnated CVCs were the only antimicrobial catheters that completely inhibited the biofilm colonization of all resistant bacterial and fungal organisms tested at all time intervals, and they were significantly superior to uncoated catheters (all P values were ≤0.003). Furthermore, CHX-M/R-coated CVCs had a significantly more effective and prolonged (up to 3 weeks) antimicrobial activity against MRSA and P. aeruginosa than M/R, CHX/SS, and uncoated CVCs (P < 0.0001). Similarly, CHX-M/R-coated PICCs were also superior to M/R-coated and CHX-coated PICCs in preventing biofilms of MRSA, VRE, P. aeruginosa, and Candida species (P value = 0.003 for all). Our study shows that novel CHX-M/R-coated catheters have unique properties in completely inhibiting biofilm colonization of MRSA, VRE, P. aeruginosa, and fungi in a manner superior to that of M/R- and chlorhexidine-treated catheters.

Response to: Antibiotic resistant infections with antibiotic-impregnated Bactiseal catheters for ventriculoperitoneal shunts

"Response to: Antibiotic resistant infections with antibiotic-impregnated Bactiseal catheters for ventriculoperitoneal shunts." British Journal of Neurosurgery, 25(6), p. 781

Antibiotic resistant infections with antibiotic-impregnated Bactiseal catheters for ventriculoperitoneal shunts

We were interested to read the article by Demetriades and Bassi1 regarding shunt infections due to rifampicin-resistant strains of Staphylococcus epidermidis in patients receiving Bactiseal shunts....

Comparison of Hospital Cost and Resource Use Associated With Antibiotic-Impregnated Versus Standard Shunt Catheters

S ince their introduction in the 1950s, cerebrospinal fluid (CSF) shunts have been the mainstay of hydrocephalus treatment. Despite improvements in preoperative and perioperative antibiotic therapy, 5% to 15% of all shunts placed in North America become infected. The clinical consequence of shunt infections in both pediatric and adult high-risk populations has been described extensively and includes reduced intelligence quotient, psychomotor retardation, and seizures. Several independent risk factors have been identified, including patient age, cause of hydrocephalus, duration of surgery, revision surgery, surgeon experience, preceding shunt infection, postoperative CSF leakage, and conversion from external ventricular drain to shunt. The direct medical cost of shunt infection has been reported to be $17 300 to $48 454, with an estimated total annual cost of $100 million. Antibiotic-impregnated shunts (AISs) were recently introduced with the aim of reducing the incidence rate of shunt-related infections. The AIS catheters release antibiotics over the course of several weeks to prevent the colonization of shunt systems by Gram-positive bacteria, which accounts for the preponderance of shunt infections. To date, the majority of published studies on this subject have demonstrated a statistically significant reduction in shunt-associated infections when AIS catheters were used; however, there has been some reluctance to adopt these systems because of their increased cost compared with conventional catheters. Furthermore, the efficacy of AIS catheters in these studies was confined to the pediatric population. Less evidence exists supporting their utility in adult hydrocephalus. We recently reported a significant reduction in the incidence of shunt infection in adult hydrocephalus after the categorical conversion to AIS catheters at our institution. In the present study, we performed a retrospective cohort study and economic analysis to determine whether the use of AIS catheters in adult hydrocephalus at our institution has been cost-effective. METHODS All adult patients undergoing CSF shunt insertion by a single surgeon (D.R.) over a 7-year period at the Johns Hopkins Hospital were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters (Bactiseal, Codman) was made. Before 2006, standard nonimpregnated shunt catheters were used. In 2006 and thereafter, AIS catheters were used in all cases regardless of patient characteristics. Once the 250th consecutive AIS shunt system was implanted in February 2009, this retrospective cohort study was initiated to determine the incidence of infection in our experience with AIS catheters. As a comparison group, the 250 consecutive patients receiving standard non-AIS CSF shunts immediately before the AIS conversion were reviewed (2004-2006). Patient demographics, CSF shunt surgery history, clinical presentation, radiological studies, operative variables, shunt type and configuration, and CSF, blood, and hardware culture data were reviewed. Only adult patients (. 21 years of age) were included. The majority of patients undergoing CSF shunting for adult hydrocephalus in our practice were treated for normalpressure hydrocephalus (NPH) or idiopathic intracranial hypertension (pseudotumor cerebri). As previously described in detail, NPH patients were shunted if they demonstrated cognitive decline, gait abnormalities, or urinary incontinence with significant improvement after trial CSF drainage. As also previously described by our group, pseudotumor cerebri patients were shunted if they had medically refractory headache or visual decline and persistently elevated opening pressures on serial lumbar punctures. Throughout the reviewed period of time (2004-2009), no modifications were made to the shunt surgery technique or procedure other than the use of AIS catheters in 2006. All procedures were done in the same surgical suites by the senior author. Moreover, the treatment of shunt infection remained standardized throughout the reviewed period. Shunt infection was defined as a clinical suspicion of shunt infection (fever, increased white blood cell count, and/or wound breakdown involving the shunt) with positive cultures Copyright 2011 by The Congress of Neurological Surgeons 0148-396X

Editorial: The less you look, the less you find

The article by Williams and colleagues2 shows a decreased incidence of ventriculitis when CSF samples are drawn from extraventricular drains (EVDs) less frequently. The authors compare a historical group of ICU patients to a prospective sample of ICU patients, in all of whom an EVD was placed for reasons not related to infections. In the historical group CSF samples were obtained daily, and in the prospective group samples were acquired every 3rd day. In the prospective group, there was a lower incidence of proven (CSF culture–positive) ventriculitis. This article describes a large experience and the study question is interesting. Even with no change in ventriculitis, reduced CSF sampling would reduce the cost of care in this group of patients. This is a welcome contribution to the literature. With the ever-escalating cost of care, we need more studies that evaluate reduced frequency interventions. In my biased opinion, I agree that we do not need daily CSF cultures drawn from EVDs, but I find limited support for my opinion in this paper for the following reasons: 1) There were more CSF cultures obtained per patient in the retrospective group. Each time we do a diagnostic test there is a risk of a false-positive result. In this situation, false positives may occur due to contamination of the specimen or detection of a clinically insignificant infection. It is therefore possible that the underlying incidence of ventriculitis is the same but the group that is tested more frequently has a higher proportion of positive tests. 2) In the prospective group, antibiotic-impregnated catheters were used. These may have contributed to a reduced infection rate or they may have resulted in falsenegative cultures in the prospective group.1 3) When the prospective data collection began, the “staff was provided with an education package on the purpose of the study and the changes in practice.” Everyone knew that a study was in progress, that the purpose was to see if ventriculitis would decrease, and that they were being watched. It has been well demonstrated that in such circumstances people “try harder.” I wonder, therefore, if the bedside nurses may have been more meticulous about CSF sample collection or wound care to avoid contamination. Although well intentioned, this could have altered the study results. 4) Formal reviews of every patient with an EVD were undertaken by the investigators in the prospective group. This kind of detailed scrutiny probably did not occur in the preintervention group and could have altered the detection of ventriculitis in a positive or negative direction. 5) The authors’ hypothesis is that accessing or opening the sterile EVD/CSF system might cause infection and that reduced sampling therefore might reduce infection. In light of that hypothesis, other occasions when the EVD/CSF system was accessed are relevant. Repeat EVD insertions or revisions might cause CSF contamination; there were more patients in the retrospective group who had multiple EVD insertions. In addition there were some patients with bilateral EVDs, but the frequency in the 2 groups was not described. Similarly, when EVDs malfunctioned, they were flushed with sterile saline and the frequency of flushing in the 2 groups was not provided. These events are opportunities for contamination of the CSF and could have altered the incidence of ventriculitis. 6) Extraventricular drains were implanted in the operating room or the ICU. Was the incidence of infection different between these 2 sites and if so were the groups balanced on location? Again, I am very happy to see assessments such as this, but I think there are a number of possible interpretations of the data: perhaps antibiotic-impregnated catheters work or result in false-negative cultures; perhaps 3rd-day sampling reduced contamination and caused the reduction in ventriculitis; or perhaps daily sampling was detecting organisms in the CSF that were contaminants or were asymptomatic and potentially resolved on their own. In other words, the more you look, the more you find, and the true underlying incidence may be completely unaffected by the sampling frequency. It may simply be that the authors detected fewer cases of “ventriculitis” because they looked less often.

Lower associated costs using rifampicin-miconazole‒impregnated catheters compared with standard catheters

Previous cost-effectiveness analyses found that antibiotic-impregnated catheters decrease the incidence of catheter-related bloodstream infection (CRBSI) as well as the costs related to central venous catheter (CVC) use, including increased hospital length of stay. The effect varied greatly among the studies, however. In this retrospective cohort study, compared with standard catheters, the use of rifampicin-miconazole-impregnated catheters was associated with lower CRBSI incidence and immediate CVC-related costs (taking into account only the costs of CVC, diagnosis, and treatment of CRBSI) (P < .001). Our data indicate that the use of rifampicin-miconazole-impregnated catheters can save associated costs.

Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Antibiotic resistant infections with antibiotic-impregnated Bactiseal catheters for ventriculoperitoneal shunts

Background. Shunts remain the commonest means by which hydrocephalus is treated. Despite the changes in valve and catheter technology, shunt infection and blockage are still a cause of great headache for the patient as well as the neurosurgeon. Antibiotic-laced catheters were proposed as a means by which to reduce shunt colonization and infection.Methods. We present our experience of 52 months of Bactiseal catheters in all consecutive patients who underwent a ventriculoperitoneal (VP) shunt from July 2004 to November 2008, under the care of one neurosurgeon. This was a prospective study with outcome measures of infection, blockage, intra and postoperative complications and revision surgery.Results. One hundred and twenty-five patients underwent VP shunting with Bactiseal catheters, with a combination of NSC, Strata and Burr Hole valves. The age range of the patients was from 1 week premature to 64-years old. Forty-two of the patients were paediatric. The aetiology for hydrocephalus included posterior fossa tumoursto intra-ventricular haemorrhage, post-meningitic hydrocephalus and aqueduct stenosis. The overall complication rate was 12%. The following complications occurred: blockage in two cases; haemorrhage and blockage in two cases; CSF leak in one case; infection in four cases; other in three cases (peritoneal adhesions, wound erosion and postoperative peritonitis). There were four infections in total (3.2%). All of these occurred within six months of implantation. All infections were caused by rifampicin resistant Staphylococcus epidermidis.Conclusion. In an era of increasing methicillin-resistant Staphylococcus aureus (MRSA) resistance and ‘superbugs’, is the use of antibiotic-laced catheters adding to the pool of resistant bacteria which may be harder to treat? Vigilance is required, as rare and resistant staphylococci strains occasionally can emerge as causative agents for VP shunt infections, in both adults and children, and their treatment can be difficult.

Intracranial pressure: why we monitor it, how to monitor it, what to do with the number and what's the future?

The review touches upon the current physiopathological concepts relating to the field of intracranial pressure (ICP) monitoring and offers an up-to-date overview of the ICP monitoring technologies and of the signal-analysis techniques relevant to clinical practice. Improved ICP probes, antibiotic-impregnated ventricular catheters and multimodality, computerized systems allow ICP monitoring and individualized optimization of brain physiology. Noninvasive technologies for ICP and cerebral perfusion pressure assessment are being tested in the clinical arena. Computerized morphological analysis of the ICP pulse-waveform can provide an indicator of global cerebral perfusion. Current recommendations for the management of traumatic brain injury indicate ICP monitoring in patients who remain comatose after resuscitation if the admission computed tomography scan reveals intracranial abnormalities such as haematomas, contusions and cerebral oedema. The most reliable methods of ICP monitoring are ventricular catheters and intraparenchymal systems. A growing number of these devices are being safely placed by neurointensivists. The consensus is to treat ICP exceeding the 20 mmHg threshold, and to target cerebral perfusion pressure between 50 and 70 mmHg. Recent evidence suggests that such thresholds should be optimized based on multimodality monitoring and individual brain physiology. Noninvasive ICP estimation using transcranial Doppler can have a role as a screening tool in patients with low to intermediate risk of developing intracranial hypertension. However, the technology remains insufficiently accurate and too cumbersome for continuous ICP monitoring.

Abstract No. 95: Central venous access in high-risk pediatric patients: Comparison of conventional and antibiotic-impregnated catheters

Abstract No. 95: Central venous access in high-risk pediatric patients: Comparison of conventional and antibiotic-impregnated catheters