External Ventricular Drain Infection Research Articles

The SILVER (Silver Impregnated Line Versus EVD Randomized Trial)

Cerebrospinal fluid (CSF) infections associated with external ventricular drain (EVD) placement attract major consequences. Silver impregnation of catheters attempts to reduce infection. To assess the efficacy of silver catheters against CSF infection. We performed a randomized, controlled trial involving 2 neurosurgical centers (June 2005 to September 2009). A total of 356 patients requiring an EVD were assessed for eligibility; 325 patients were enrolled and randomized (167 plain, 158 silver); 278 patients were analyzed (140 plain, 138 silver). The primary outcome measure was CSF infection as defined by organisms seen on Gram stain or isolated by culture. Secondary outcome measures included ventriculoperitoneal (VP) shunting. There was a significant difference in infection risk between the 2 study arms: 21.4% (30/140) for plain catheters vs 12.3% (17/138) for silver catheters (P = .0427; 95% confidence interval [CI]: 1.015-3.713). Patients who had an EVD infection had more than double the risk of requiring a VP shunt compared with patients without an EVD infection (45.7% [21/46] vs 19.7% [45/229], respectively, P = .0002; 95% CI: 1.766-6.682). There was also a significant difference in VP shunt risk with infection: plain (55.2%; 16/29) vs the silver arm (29.4%; 5/17); P = .0244 (95% CI: 1.144-11.695). A multivariate analysis demonstrated that infection risk was increased by duration of EVD placement (odds ratio: 1.160), spontaneous intracranial hemorrhage (odds ratio 4.958) and decreased by silver catheters (odds ratio: 0.423). The study provides Class I evidence that silver-impregnated catheters reduce CSF infection.

A Multidisciplinary Approach to End External Ventricular Drain Infections in the Neurocritical Care Unit

External ventricular drain (EVD) placement is a common practice in neurocritical care units. The EVDs are the "gold" standard and the most cost-effective treatment for intracranial hypertension and hydrocephalus caused by a variety of neurological conditions. The EVD drains excess cerebrospinal fluid in an attempt to maintain balance within the cranial vault and provides intermittent monitoring of intracranial pressure. This invasive procedure, as with any other procedures, carries an increased risk of a device-related infection that can lead to devastating consequences such as meningitis, ventriculitis, and death. This article will discuss how Riverside Methodist Hospital, which is located in Central Ohio, identified an increase in the rate of EVD infections in 2007 and responded with changes in procedure and processes. The implementation of the improvement plan has resulted in 25 months without an EVD infection, a triumph for the patients, staff, and the hospital system.

External ventricular drain infection: improved technique can reduce infection rates

Introduction. The placement of external ventricular drain (EVD) is a common neurosurgical procedure to drain cerebrospinal fluid (CSF) in many acute neurosurgical conditions that disrupt the normal CSF absorption pathway. Infection is the primary complication with infection rates ranging between 0% and 45%, and this is associated with significant morbidity and mortality, prolonged hospital stay and increased hospital costs.This article compares and discusses the differences in rates of EVD CSF infection between clinical neurosurgical practice and the infection rates in a group of research patients where EVDs were sampled frequently as part of the study.Materials and methods. Patients who had EVD placed were identified by review of theatre logs from 2005–2008. A retrospective case-note review was performed with the primary end point being those patients treated with intrathecal antibiotics. Patients within the research group were identified from established data and the same primary endpoint was used. A standard silicone catheter was the EVD used in both cohorts. Patients were excluded if the EVD was placed for diagnoses other than hydrocephalus associated with aneurysmal subarachnoid haemorrhage (SAH).Results. Ninety-four patients had 156 EVDs placed within the clinical group, 49 patients were treated giving an infection rate within this group of 52.1% per patient and 31.4% per EVD. Thirty-nine patients had 39 EVDs placed within the research group, four patients were treated, the infection rate within this group was 10.3% per EVD, p = 0.0001.Conclusion. Sampling or irrigating ventricular drainage systems does not increase the risk of CNS infection providing the operator has appropriate experience and has used theatre standard aseptic technique.

Checklists and Bundles-Not Just for Central Lines Anymore: Using a Standardized Insertion and Maintenance Approach to Eliminate External Ventricular Drain Infections

External ventricular drains (EVD) are often used in neuro-critical care (NCC) as treatment for neurological conditions that increase intracranial pressure. Although this therapy can be life saving, it comes with a high risk of infection. Most of the care givers considered these infections to be a non-avoidable consequence of treatment prior to the project. A cluster of infections prompted a review of the current process for inserting and maintaining EVDs.

Erratum to: Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters

Erratum to: Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters

Reduction in external ventricular drain infection rate. Impact of a minimal handling protocol and antibiotic-impregnated catheters

Many strategies have been developed with the aim of reducing external ventricular drain-related infections. Antibiotic-impregnated catheters are one of them. We report 648 cases of external ventricular drain from a total of 534 patients treated at the Virgen del Rocío Hospital between 1995 and 2006. Three subgroups were considered: group 1 included patients treated between 1995 and 2000, as well as a total of 190 external ventricular drains and 59 cases of infection (31.05%); group 2, with patients treated between 2000 and 2004 and managed with a minimal handling protocol, included 210 external ventricular drains and nine cases of infection (4.29%); and group 3, treated between 2004 and 2006, with 248 external ventricular drains and six cases of infection (2.41%). This latter subgroup included patients managed with a minimal handling protocol and antibiotic-impregnated catheters. Infection rate was 17% when non-antibiotic-impregnated catheters were employed and 2.41% when antibiotic-impregnated catheters were inserted (p < 0.001). This difference was statistically significant before and after the introduction of a minimal handling protocol, with percentages of 5.31% and 3.27%, respectively (p < 0.001; odds ratio 0.08; absolute risk reduction 27.26%). However, no statistically significant difference was observed in infection rate when the impact of a minimal handling protocol was considered: 4.29% when only the protocol was introduced and 2.41% when both the protocol and antibiotic-impregnated catheters were used (p > 0.05). Minimal handling protocols constitute an essential strategy in the reduction of external ventricular drain-related infections. Besides that, the use of antibiotic-impregnated catheters may reduce infection-related hospital costs.

Efficacy of antibiotic-impregnated external ventricular drain catheters

We prospectively compared the incidence of ventriculitis associated with external ventricular drains (EVD) impregnated with clindamycin and rifampicin with historical controls. We found the use of antibiotic impregnated (AI) EVDs showed a significant decrease in positive cerebrospinal fluid cultures and a significant delay in time to EVD infection.

External ventricular drains in pediatric patients*

To determine the indications and complications of external ventricular drain (EVD) placement in pediatric patients. Retrospective chart review. University associated, tertiary-level Children's Hospital. Sixty-six [median age, 10.1 years (interquartile range, 5.9)] patients between 1994 and 2006 with 96 EVDs. Clinical indications for EVD insertion include traumatic brain injury (TBI; 36%), acute hydrocephalus (35%), and ventriculoperitoneal shunt failure (29%). Of the 96 EVDs, 65% were inserted at the bedside in the pediatric critical care unit (PCCU) and 33% in the operating room (OR). Median duration of EVD insertion was 7.0 days (interquartile range, 8.8). Complications occurred with 26% of EVD insertions and included infection (9.4%), misplacement (6.3%), hemorrhage (4.2%), obstruction (3.1%), and malfunction (3.1%). The primary infectious etiology was coagulase-negative Staphylococcus (67% of infections). Despite patients with TBI having significantly smaller lateral ventricles than hydrocephalus patients (p < 0.05), EVD complications were similar (risk ratios 1.41; 95% confidence interval 0.68-2.72). Furthermore, the complication rate was the same for EVDs inserted in either the PCCU or OR (risk ratios 1.10; 95% confidence interval 0.55-2.29). EVDs were placed for TBI, ventriculoperitoneal shunt failure and new-onset hydrocephalus. The overall complication rate was 26%. Complication rates were similar in TBI and hydrocephalus patients, and with EVDs inserted in either the PCCU or OR. Prophylactic antibiotics or antimicrobial-impregnated catheters directed against coagulase-negative Staphylococcus may reduce EVD infections.

External ventricular drain infections are independent of drain duration: an argument against elective revision

External ventricular drain infections are independent of drain duration: an argument against elective revision

External Ventricular Drain Infection

Object The authors explored the relationship among the duration of external ventricular drainage, revision of external ventricular drains (EVDs), and cerebrospinal fluid (CSF) infection to shed light on the practice of electively revising these drains. Methods In a retrospective study of 199 patients with 269 EVDs in the intensive care unit at a major trauma center in Australasia, the authors found 21 CSF infections. Acinetobacter accounted for 10 (48%) of these infections. Whereas the duration of drainage was not an independent predictor of infection, multiple insertions of EVDs was a significant risk factor. Second and third EVDs in previously uninfected patients were more likely to become infected than first EVDs. An EVD infection was initially identified a mean of 5.5 ±0.7 days postinsertion (standard error of the mean); these data—that is, the number of days—were normally distributed. Conclusions This pattern of infection is best explained by EVD-associated CSF infections being acquired by the introduction of bacteria on insertion of the drain rather than by subsequent retrograde colonization. Elective EVD revision would be expected to increase infection rates in light of these results, and thus the practice has been abandoned by the authors' institution.

External ventricular drain infections are independent of drain duration: an argument against elective revision

The authors explored the relationship among the duration of external ventricular drainage, revision of external ventricular drains (EVDs), and cerebrospinal fluid (CSF) infection to shed light on the practice of electively revising these drains. In a retrospective study of 199 patients with 269 EVDs in the intensive care unit at a major trauma center in Australasia, the authors found 21 CSF infections. Acinetobacter accounted for 10 (48%) of these infections. Whereas the duration of drainage was not an independent predictor of infection, multiple insertions of EVDs was a significant risk factor. Second and third EVDs in previously uninfected patients were more likely to become infected than first EVDs. An EVD infection was initially identified a mean of 5.5 +/- 0.7 days postinsertion (standard error of the mean); these data--that is, the number of days--were normally distributed. This pattern of infection is best explained by EVD-associated CSF infections being acquired by the introduction of bacteria on insertion of the drain rather than by subsequent retrograde colonization. Elective EVD revision would be expected to increase infection rates in light of these results, and thus the practice has been abandoned by the authors' institution.

Extended subcutaneous tunnelling technique for external ventricular drainage

Infection is a serious complication of external ventricular drain (EVD) and various strategies have been adopted to minimize its occurrence. The use of an extended subcutaneous tunnel (50 – 60 cm) was previously described, but has since received little attention in the literature. The authors reviewed their experience with this technique, with emphasis on the rate of infection and predisposing risk factors. This is a retrospective review of 114 patients who received EVD with extended subcutaneous tunnel (‘long EVD’). Fourteen of the 114 patients underwent more than one insertion, and a total of 133 cases of ‘long EVD’ were included. The mean duration of drainage was 20 days. One-hundred-and-three cases started without pre-existent infection and seven became infected, yielding an overall infection rate of 6.8%. The majority of infections were found within the first 5 days and in the third week of drainage. There was, however, no statistically significant difference in daily infection risks between the first, second and third weeks. Only intraventricular instillation of urokinase was identified as a statistically significant risk factor. Non-infective complications occurred in 17 cases (12.8%). In the present study, the overall infection rate of the ‘long EVD’ was comparable with that of conventional EVD, as reported by other authorities in the literature. The extended subcutaneous tunnel technique did not affect the daily infection risk on a week-to-week basis. The ‘long EVD’ does not appear to offer any distinct advantage over the standard tunnelling technique in our unit. However, this is essentially an audit within a single centre, and the findings should be interpreted with caution and with the understanding that individual institutions may have their unique patterns and risks of EVD infection.

External ventricular drain infection: the effect of a strict protocol on infection rates and a review of the literature

External ventricular drains (EVDs), like any surgically-implanted foreign body, are at risk of infection. We present the results of a completed audit loop following introduction of an evidence-based protocol for their insertion and management. There were two phases over a 2-year period. Phase 1 was a retrospective audit of our EVD infection rate. Phase 2 was a prospective audit of the infection rate subsequent to the introduction of a protocol for the insertion and management of EVDs. In phase 1, the infection rate was 27%. In phase 2, the infection rate was 12%. This was a statistically significant reduction (p < 0.05, Chi-squared test). EVD infection is unfortunately a common clinical problem and associated with potential morbidity and mortality. This study demonstrates that adherence to an evidence-based protocol for their insertion and management is associated with a significant reduction in the infection rate.

Infection Rates in Standard vs. Hydrogel Coated Ventricular Catheters

Infection related to external ventricular drain (EVD) use is a common neurosurgical complication. Modified catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter related cerebrospinal fluid (CSF) infection. A prospective randomized clinical trial compared the occurrence of CSF infection related to use of either standard silastic or hydrogel coated EVD catheters (Bioglide, Medtronic). Enrolment was available to all adult neurosurgery patients undergoing placement of a first EVD, at three university centers. The catheters were presoaked in a low concentration of bacitracin solution for 5-10 minutes prior to insertion. Bacterial infection was defined by heavy growth in a single CSF sample or light/medium growth in two consecutive samples. A secondary analysis was also conducted for "probable" CSF infection, including patients started on antibiotics after light/medium growth in a single CSF sample. Statistical analyses included Kaplan-Meier survival curve estimates accompanied by Log Rank and Breslow tests. There were 158 randomized patients available to assess for EVD related infection of CSF. The two study groups had similar clinical characteristics including average duration of EVD use (8 +/- 4 days). Definite CSF infection occurred in seven and probable infection in another six (8% total). Infection incidence rose steadily from day 2 (1%) to day 11 (11%). There was no difference of daily occurrence of EVD infection between the two catheter types. Infection remains a common hazard in the use of EVD, and we found no reduction of infection using the hydrogel-coated catheters when presoaked in low concentration bacitracin solution.