Antibiotic-impregnated Shunt Research Articles

In Reply: Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis.

In Reply: Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis.

Letter: Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis.

Letter: Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis.

Antibiotic-impregnated shunts: a paradigm shift in hydrocephalus management

Antibiotic-impregnated shunts: a paradigm shift in hydrocephalus management

Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis.

Antibiotic-impregnated shunts seem to be beneficial in preventing bacterial infections and decreasing mortality by effectively inhibiting microbial growth in the shunt system and reducing the risk of shunt-associated infections. This study aimed to evaluate the efficacy of antibiotic-impregnated shunt catheters (AISC) in reducing the incidence of bacterial shunt infection in patients with hydrocephalus. The protocol was registered on PROSPERO. A meta-analysis was conducted by searching 3 databases (PubMed, Scopus, CENTRAL) for relevant randomized controlled trials and observational studies. We included all studies published until November 2022 in any language. The primary outcome was the rate of bacterial infections, whereas the rate of shunt failure was our secondary endpoint. Odds ratios (OR) with 95% CI were calculated using a random-effects model. A total of 27 articles with 27 266 shunt operations were included in this study. The results indicated that using AISC is significantly associated with reduction in infections (OR = 0.42; 95% CI: 0.33-0.54). Regarding shunt failure, there was a tendency in favor of AISC use (OR = 0.73; 95% CI: 0.51-1.06). Our study provided evidence that AISC is significantly associated with the reduction in the rate of bacterial ventriculoperitoneal-shunt infection. In addition, there was a tendency toward AISC to decrease shunt failure compared with the standard shunt.

Antibiotic impregnation and nanocoating of external ventricular drainage catheters for antibacterial applications: Evaluation of in vitro studies and molecular docking.

The most suitable method to treat hydrocephalus disease is to insert a shunt catheter that drains the cerebral spinal fluid (CSF); however, shunt implantation is often associated with various bacterial infections. In this study, antibiotic-loaded nanospheres were prepared using the solvent evaporation technique and coated on an antibiotic-impregnated shunt surface to promote shunt antibacterial properties. Clindamycin (CDM) and rifampicin (RIF) were in combination loaded in a single nanosphere, whereas trimethoprim (TMP) was loaded individually in triblock copolymers [(d,l-lactide-random-ε-caprolactone)-block-poly(ethylene glycol)-block-(d,l-lactide-random-ε-caprolactone)] (PLEC). The drug-loading content, encapsulation efficiency, yield, size, and zeta potential of the antibiotic-loaded nanospheres were measured. The results showed that the drug-loading content of clindamycin- and rifampicin-loaded nanospheres (CDM/RIF-NPs) was approximately 3% and 8%, respectively, at a drug to polymer ratio of 1:2. In addition, trimethoprim-loaded nanospheres (TMP-NPs) showed nearly 7% drug loading at equal drug and polymer ratios. The amount of drug release was determined before and after the coating of nanospheres on the shunt surface. In addition, in silico molecular docking studies indicated the good chemical interaction of these antibiotics with PLEC, and the results were consistent with those of impregnation studies. Antibacterial tests of coated external ventricular drainage showed antibacterial activity for up to 21 days.

Outcome of Antibiotic-Impregnated Shunt (AIS) Catheters for Management of Hydrocephalus: A Retro-Prospective Study versus Non-AIS Catheters

Outcome of Antibiotic-Impregnated Shunt (AIS) Catheters for Management of Hydrocephalus: A Retro-Prospective Study versus Non-AIS Catheters

Actions of N-acetylcysteine, daptomycin, vancomycin, and linezolid on methicillin-resistant Staphylococcus aureus biofilms in the ventriculoperitoneal shunt infections: an experimental study

BackgroundShunt systems are used to provide cerebrospinal fluid drainage in the treatment of hydrocephalus. Recently, antibiotic-impregnated shunt systems are used to prevent colonization in the ventriculoperitoneal catheters. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common causative microorganism of shunt infections. The aim of the study is to investigate effects of several substances on MRSA biofilms in the ventriculoperitoneal catheters.MethodsThe present study consists of mainly eight groups (each has two subgroups as antibiotic-impregnated and nonantibiotic-impregnated catheters). In addition, each group contains six molds using MRSA strains. In this study, daptomycin (DAPT) (2 mg/ml), vancomycin (VAN) (10 mg/ml), linezolid (LIN) (2 mg/ml), N-acetylcysteine (NAC) (6 mg/ml), and various combinations of these substances were used to evaluate the treatment against MRSA using scanning electron microscope (SEM) images and microbiological enumeration.ResultsThe colony count in the antibiotic-impregnated samples significantly decreased compared to nonantibiotic-impregnated samples in the MRSA, MRSA + DAPT, and MRSA + LIN groups (p < 0.01), respectively. Conversely, the colony count in antibiotic-impregnated samples significantly increased compared to nonantibiotic-impregnated samples in NAC + DAPT and NAC + VAN groups (p < 0.01), respectively.ConclusionsThe results showed that the use of antibiotic-impregnated catheters has a significant impact on the prevention of infection whereas the combination of NAC and DAPT showed better antibiofilm and antibacterial effects than other combinations on the prevention and treatment of nonantibiotic-impregnated catheter infections.

Combined early myelomeningocele repair and antibiotic-impregnated ventriculoperitoneal shunt insertion in treatment of Chiari 2 malformation with overt hydrocephalus: Outcome of 25 consecutive cases

Combined early myelomeningocele repair and antibiotic-impregnated ventriculoperitoneal shunt insertion in treatment of Chiari 2 malformation with overt hydrocephalus: Outcome of 25 consecutive cases

The collagen matrix dural substitute graft prevents postoperative cerebrospinal fluid leakage after ventriculoperitoneal shunt surgery in patients aged

Cerebrospinal fluid (CSF) leakage is a common complication of ventriculoperitoneal shunt (VPS) and has the potential to induce shunt infection. Especially in infants and children, these are serious complications. DuraGen is a collagen matrix dural substitute used to reduce the risk of CSF leakage in various neurosurgeries. We report our VPS procedure with DuraGen for preventing postoperative CSF leakage in patients aged <1 year. We used DuraGen to prevent postoperative CSF leakage in six VPS surgeries. Antibiotic-impregnated shunt catheters and programmable valves with anti-siphon devices were also used in all cases. DuraGen was placed inside and atop the burr hole. All cases had an initial shunt pressure of 5 cmH2O. Fibrin glue was not used. The patients underwent follow-up for a year after VPS surgery. There was no postoperative subcutaneous CSF collection or leakage after all six VPS surgeries. Furthermore, no postoperative shunt infections or DuraGen-induced adverse events were noted. We speculate that DuraGen has a preventive effect on postoperative CSF leakage in VPS cases aged <1 year.

A Prospective Study and Analysis of Ventriculoperitoneal Shunt Surgery: Their Indication and Complication in a Single Tertiary Care Center

Abstract Background Ventriculoperitoneal (VP) shunt insertion is routinely performed for the treatment of hydrocephalus due to different indications like congenital, infective, tumor, posttraumatic, and normal pressure hydrocephalus (NPH). A lot of common and rare complications following this procedure have been reported. Objectives To analyze the clinical profile, indications, anesthetic, and postoperative complications for VP shunt surgery in our center. Materials and Methods This prospective clinical review study was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, between October 2018 to January 2020 and included 454 cases of hydrocephalus who underwent VP shunt surgery. The data was compiled and analyzed. Results A total of 454 patients with male predominance were studied. Pediatric and adolescent patients were 48.9% (222/454). Obstructive hydrocephalus due to tumors was the etiology of 48.7% (221/454) cases. The incidence of overall shunt complications was 9.7% (44/454), of which obstruction and infection was 5.9% (27/454) and 3.1% (14/454), respectively. Factors associated with increased shunt complications include redo and infective etiology and cases having higher protein in perioperative cerebrospinal fluid (CSF) analysis. Neuronavigation, antibiotic-impregnated shunt and biventricular shunt are associated with lower complications. Conclusion Obstructive hydrocephalus due to tumors happened to be the most common cause of VP shunt, and shunt obstruction is most common complication, especially in infective and redo cases.

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

Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts. To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement. This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection. A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio=0.29, 95% CI: 0.04-0.89, P=.038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection. These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.

Systematic Review and Meta-Analysis of Antibiotic-Impregnated Shunt Catheters on Anti-Infective Effect of Hydrocephalus Shunt.

ObjectiveShunt infection is a common complication while treating hydrocephalus. The antibiotic-impregnated shunt catheter (AISC) was designed to reduce shunt infection rate. A meta-analysis was conducted to study the effectiveness of AISCs in reduction of shunt infection in terms of age, follow-up time and high-risk patient population. MethodsThis study reviewed literature from three databases including PubMed, EMBASE, and Cochrane Library (from 2000 to March 2019). Clinical studies from controlled trials for shunt operation were included in this analysis. A subgroup analysis was performed based on the patient’s age, follow-up time and high-risk population. The fixed effect in RevMan 5.3 software (Cochrane Collaboration) was used for this meta-analysis. ResultsThis study included 19 controlled clinical trials including 10105 operations. The analysis demonstrated that AISC could reduce the infection rate in shunt surgery compared to standard shunt catheter (non-AISC) from 8.13% to 4.09% (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.40–0.58; p=0.01; I2=46%). Subgroup analysis of different age groups showed that AISC had significant antimicrobial effects in all three groups (adult, infant, and adolescent). Follow-up time analysis showed that AISC was effective in preventing early shunt infections (within 6 months after implant). AISC is more effective in high-risk population (OR, 0.24; 95% CI, 0.14–0.40; p=0.60; I2=0%) than in general patient population. ConclusionThe results of meta-analysis indicated that AISC is an effective method for reducing shunt infection. We recommend that AISC should be considered for use in infants and high-risk groups. For adult patients, the choice for AISC could be determined based on the treatment cost.

Techniques and Nuances in Ventriculoperitoneal Shunt Surgery.

Ventriculoperitoneal shunt surgery (VPS) is a simple solution to the problem of hydrocephalus. However, it is associated with significant complications. Meticulous attention to a variety of factors, techniques, and nuances in VPS can reduce these complications. To review the various techniques and nuances during the different stages of VPS. PubMed search for original and review articles dealing with various techniques used during VPS. Thorough preoperative planning for VPS reduces operative time and complications. A standardized shunt surgery protocol significantly reduces shunt infection. Good and appropriate surgical technique can enhance the safety of the procedure. Anterior entry point is better than posterior entry point. Shunt tip should be away from choroid plexus, but the exact location is not vital for shunt survival. Proper placement of the shunt in the subgaleal and subcutaneous plane reduces wound and skin breakdown over the shunt. The trocar and laparoscopic methods to access the peritoneum are associated with fewer distal obstructions compared to mini-laparotomy. Perioperative antibiotic prophylaxis, use of antibiotic-impregnated shunts, and sutures are proven techniques to reduce shunt infection. Preoperative planning, a standardized shunt surgery protocol, good surgical technique, gentle tissue handling, and short surgery duration are essential to reduce VPS complications. Specifically, use of anterior entry point, correct tunneling of the shunt in the subgaleal and subcutaneous plane, appropriate antibiotic prophylaxis, use of antibiotic-impregnated shunts, and meticulous skin closure using antimicrobial sutures can lead to a reduction in shunt malfunction and infection.

PND53 Budget IMPACT Analysis of the Antibiotic-Impregnated Ventriculoperitoneal Shunt VS Standard Silicone Shunt in Patients with Hydrocephalus in England, France, Germany and Italy

Hydrocephalus is the pathological accumulation of cerebrospinal fluid in the cerebral ventricles. If left untreated, progressive hydrocephalus leads to high mortality and severe neurological outcomes. The most common treatment method is the placement of the ventriculoperitoneal shunt (VPS). The objective of the study was to evaluate the budget impact of antibiotic-impregnated VPS vs. standard silicone VPS on healthcare systems in England, France, Germany, and Italy over a one-year time horizon. Decision-analytic modelling was used. The model considered the initial placement of the shunt and revision surgery due to catheter-related infections and other reasons. Clinical data were obtained from the BASICS RCT and the UK Shunt Registry. Cost data were obtained from the local sources. The analysis was performed for a cohort of 100 patients, including a mix of adult and pediatric patients. The use of the antibiotic-impregnated VPS led to a reduction of infection-related revisions by 3.87 for the cohort of 100 patients. When only infection-related revisions were considered, the budget impact of antibiotic-impregnated VPS was -£50,220 in England, -€23,076 in France, -€22,445 in Germany, and -€29,362 in Italy for the cohort of 100 patients. When all types of revisions were considered, antibiotic-impregnated VPS was still cost saving to the system, but the magnitude of saving was smaller. In summary, the use of antibiotic-impregnated shunt leads to better patient outcomes, reduced morbidity, and reduced cost to the health care system. The use of antibiotic-impregnated shunts should be prioritized over standard silicone shunts to achieve the best clinical and economic outcomes.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Treatment of Pediatric Hydrocephalus: Update of the 2014 Guidelines.

The Congress of Neurological Surgeons reviews its guidelines according to the Institute of Medicine's recommended best practice of reviewing guidelines every 5 yrs. The authors performed a planned 5-yr review of the medical literature used to develop the "Pediatric hydrocephalus: systematic literature review and evidence-based guidelines" and determined the need for an update to the original guideline based on new available evidence. To perform an update to include the current medical literature for the "Pediatric hydrocephalus: systematic literature review and evidence-based guidelines", originally published in 2014. The Guidelines Task Force used the search terms and strategies consistent with the original guidelines to search PubMed and Cochrane Central for relevant literature published between March 2012 and November 2019. The same inclusion/exclusion criteria were also used to screen abstracts and to perform the full-text review. Full text articles were then reviewed and when appropriate, included as evidence and recommendations were added or changed accordingly. A total of 41 studies yielded by the updated search met inclusion criteria and were included in this update. New literature resulting from the update yielded a new recommendation in Part 2, which states that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement (LevelIII). Additionally a recommendation in part 7 of the guideline now states that antibiotic-impregnated shunt tubing reduces the risk of shunt infection compared with conventional silicone hardware and should be used for children who require placement of a shunt (LevelI). <https://www.cns.org/guidelines/browse-guidelines-detail/pediatric-hydrocephalus-guideline>.

PND17 Budget IMPACT Analysis of the Recourse to Antibiotic-Impregnated Shunt Catheters VS Standard Silicone Catheters in Patients with Hydrocephalus

PND17 Budget IMPACT Analysis of the Recourse to Antibiotic-Impregnated Shunt Catheters VS Standard Silicone Catheters in Patients with Hydrocephalus

Efficacy of antibiotic-impregnated shunt versus conventional shunts to reduce cerebrospinal fluid infections in children: A systematic review and meta-analysis.

Hydrocephalus is among the most common pediatric conditions treated by neurosurgeons. An antibiotic-impregnated shunt (AIS) was designed to reduce the rate of shunt infections. The objective of this systematic review and meta-analysis was to assess the efficiency of AIS in reducing the rate of shunt infection compared with standard shunts (SSs). A systematic search of PubMed, EMBASE, Medline, Cochrane Library, TRIP Database, CINAHL and Google Scholar databases was performed. Eligible studies included observational studies and randomized controlled trials (RCT) that compared the effects of AIS and SS for preventing shunt infections in pediatric patients. Twelve observational studies and one RCT conducted from January 2005 through October 2019 involving 7,952 pediatric patients were included in the analysis. The use of AIS significantly decreased the risk of CRI [risk ratio (RR) 0.42; 95% confidence interval: 0.33 to 0.53; P<0.00001] with no statistical heterogeneity across the included studies (I2=42%). This analysis demonstrates that the use of AIS significantly reduces the risk of shunt infection in pediatric patients.

Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey.

Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment. We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures. A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment. A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 109/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively. Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.

Silver-impregnated, antibiotic-impregnated or non-impregnated ventriculoperitoneal shunts to prevent shunt infection: the BASICS three-arm RCT.

Insertion of a ventriculoperitoneal shunt to treat hydrocephalus is one of the most common neurosurgical procedures worldwide. Shunt infection affects up to 15% of patients, resulting in long hospital stays, multiple surgeries and reduced cognition and quality of life. The aim of this trial was to determine whether or not antibiotic-impregnated ventriculoperitoneal shunts (hereafter referred to as antibiotic shunts) (e.g. impregnated with rifampicin and clindamycin) or silver-impregnated ventriculoperitoneal shunts (hereafter referred to as silver shunts) reduce infection compared with standard ventriculoperitoneal shunts (hereafter referred to as standard shunts). This was a three-arm, superiority, multicentre, parallel-group randomised controlled trial. Patients and a central primary outcome review panel, but not surgeons or operating staff, were blinded to the type of ventriculoperitoneal shunt inserted. The trial was set in 21 neurosurgical wards across the UK and the Republic of Ireland. Participants were patients with hydrocephalus of any aetiology who were undergoing insertion of their first ventriculoperitoneal shunt. Participants were allocated 1 : 1 : 1 by pressure-sealed envelope to receive a standard non-impregnated, silver-impregnated or antibiotic-impregnated ventriculoperitoneal shunt at the time of insertion. Ventriculoperitoneal shunts are medical devices, and were used in accordance with the manufacturer's instructions for their intended purpose. The primary outcome was time to ventriculoperitoneal shunt failure due to infection. Secondary outcomes were time to failure for any cause, reason for failure (infection, mechanical), types of ventriculoperitoneal shunt infection, rate of infection after first clean (non-infected) revision and health economics. Outcomes were analysed by intention to treat. Between 26 June 2013 and 9 October 2017, 1605 patients from neonate to 91 years of age were randomised to the trial: n = 36 to the standard shunt, n = 538 to the antibiotic shunt and n = 531 to the silver shunt. Patients who did not receive a ventriculoperitoneal shunt (n = 4) or who had an infection at the time of insertion (n = 7) were not assessed for the primary outcome. Infection occurred in 6.0% (n = 32/533) of those who received the standard shunt, in 2.2% (n = 12/535) of those who received the antibiotic shunt and in 5.9% (n = 31/526) of those who received the silver shunt. Compared with the standard shunt, antibiotic shunts were associated with a lower rate of infection (cause-specific hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80) and a decreased probability of infection (subdistribution hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80). Silver shunts were not associated with a lower rate of infection than standard shunts (cause-specific hazard ratio 0.99, 97.5% confidence interval 0.56 to 1.74). The ventriculoperitoneal shunt failure rate attributable to any cause was 25.0% overall and did not differ between arms. Antibiotic shunts save £135,753 per infection avoided. There were no serious adverse events. It was not possible to blind treating neurosurgeons to the ventriculoperitoneal shunt type. The return rate for patient-reported outcomes was low. Limitations to the economic evaluation included failure to obtain Hospital Episode Statistics data from NHS Digital, as per protocol. Reliance on patient-level information and costing systems data mitigated these limitations. Antibiotic shunts have a reduced infection rate compared with standard shunts, whereas silver shunts do not. Antibiotic shunts are cost-saving. A sample collection has been established that will enable the study of surrogate markers of ventriculoperitoneal shunt infection in cerebrospinal fluid or blood using molecular techniques. A post hoc analysis to study factors related to shunt failure will be performed as part of a future study. An impact analysis to assess change in practice is planned. Current Controlled Trials ISRCTN49474281. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 17. See the NIHR Journals Library website for further project information.

Antibiotic or silver versus standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation

SummaryBackgroundInsertion of a ventriculoperitoneal shunt for hydrocephalus is one of the commonest neurosurgical procedures worldwide. Infection of the implanted shunt affects up to 15% of these patients, resulting in prolonged hospital treatment, multiple surgeries, and reduced cognition and quality of life. Our aim was to determine the clinical and cost-effectiveness of antibiotic (rifampicin and clindamycin) or silver shunts compared with standard shunts at reducing infection.MethodsIn this parallel, multicentre, single-blind, randomised controlled trial, we included patients with hydrocephalus of any aetiology undergoing insertion of their first ventriculoperitoneal shunt irrespective of age at 21 regional adult and paediatric neurosurgery centres in the UK and Ireland. Patients were randomly assigned (1:1:1 in random permuted blocks of three or six) to receive standard shunts (standard shunt group), antibiotic-impregnated (0·15% clindamycin and 0·054% rifampicin; antibiotic shunt group), or silver-impregnated shunts (silver shunt group) through a randomisation sequence generated by an independent statistician. All patients and investigators who recorded and analysed the data were masked for group assignment, which was only disclosed to the neurosurgical staff at the time of operation. Participants receiving a shunt without evidence of infection at the time of insertion were followed up for at least 6 months and a maximum of 2 years. The primary outcome was time to shunt failure due the infection and was analysed with Fine and Gray survival regression models for competing risk by intention to treat. This trial is registered with ISRCTN 49474281.FindingsBetween June 26, 2013, and Oct 9, 2017, we assessed 3505 patients, of whom 1605 aged up to 91 years were randomly assigned to receive either a standard shunt (n=536), an antibiotic-impregnated shunt (n=538), or a silver shunt (n=531). 1594 had a shunt inserted without evidence of infection at the time of insertion (533 in the standard shunt group, 535 in the antibiotic shunt group, and 526 in the silver shunt group) and were followed up for a median of 22 months (IQR 10–24; 53 withdrew from follow-up). 32 (6%) of 533 evaluable patients in the standard shunt group had a shunt revision for infection, compared with 12 (2%) of 535 evaluable patients in the antibiotic shunt group (cause-specific hazard ratio [csHR] 0·38, 97·5% CI 0·18–0·80, p=0·0038) and 31 (6%) of 526 patients in the silver shunt group (0·99, 0·56–1·74, p=0·96). 135 (25%) patients in the standard shunt group, 127 (23%) in the antibiotic shunt group, and 134 (36%) in the silver shunt group had adverse events, which were not life-threatening and were mostly related to valve or catheter function.InterpretationThe BASICS trial provides evidence to support the adoption of antibiotic shunts in UK patients who are having their first ventriculoperitoneal shunt insertion. This practice will benefit patients of all ages by reducing the risk and harm of shunt infection.FundingUK National Institute for Health Research Health Technology Assessment programme.