Reduce Shunt Infection Research Articles

Implementation of an adapted perioperative ventriculoperitoneal shunting protocol in a tertiary center located in a low-to-middle-income country.

Preventative protocols have efficaciously reduced shunt infection in developed countries. However, the generalizability of these protocols in low-to-middle-income countries (LMICs) remains unclear. Previously, shunt insertion in the authors' center was routinely performed under institutional preventative precautions, which was updated via merging with the Hydrocephalus Clinical Research Network (HCRN) protocol. This study aimed to investigate the ventriculoperitoneal shunt (VPS) infection rates in pediatric patients following the implementation of the adapted protocol. The adapted protocol was implemented in all first-time VPS implantations between 2011 and 2021. The primary outcome was a 6-month shunt infection. The Pearson chi-square test was used for categorical variables and the Mann-Whitney U-test for numeric variables to evaluate the correlation with shunt infection. A total of 352 first-time VPS procedures were performed adhering to the adapted protocol. The median age was 5months, and 189 (53.7%) were male. Overall, 37 patients (10.5%) experienced shunt infection, with 30 (8.5%) occurring within the first 6months, which was lower than 13.3% infection rate of the previous series of the same center. The infection rate was slightly higher than the 5.7% and 6.0% rates reported by HCRN studies. Patients with shunt infection were significantly younger (7.5 versus 17.5months, P < 0.001). This study validates the efficacy of an adapted perioperative protocol in mitigating shunt infection in a high-volume center in a LMIC. Adhering to a step-by-step protocol, modified to suit the healthcare resources and financial constraints of LMICs, could maintain low shunt infection rates that are roughly comparable to those of centers in high-income countries.

Randomized trial of shunt infection rates comparing intraoperative Vancomycin versus Gentamicin in ventriculoperitoneal shunt system preparation

BackgroundVentriculoperitoneal (VP) shunt is the mainstay of surgical management of patients with hydrocephalus. The insertion of ventriculoperitoneal shunt may be accompanied by many potentially life-threatening complications including shunt infection. Concerted efforts have been made to reduce shunt infection rates, including use of saline- antibiotic solutions containing antibiotics such as Gentamicin, mixture of Gentamicin and Vancomycin in shunt system preparation. We therefore set out to determine the infection rates following the use of intraoperative Gentamicin and Vancomycin in ventriculoperitoneal shunt system preparation and compare the infection rates. Therefore, a randomized single blind comparative study was carried out for a period of seventeen months, among 56 patients that presented to 2 tertiary health centers in Nigeria diagnosed of hydrocephalus. Patients were randomized into Vancomycin- and Gentamicin-shunt preparation groups. The outcome measure was postoperative shunt infection rates. Statistical analysis was performed using SPSS software (version) 21. Group comparisons were made using the Student's t-test for numerical variables, and chi-square test or fisher’s exact test for categorical variables. Statistical significance was inferred at p-value < 0.05.ResultFifty-six patients were included in the study. One patient was lost to follow-up in Vancomycin group. Another patient died in Gentamicin group of sudden death without the patient exhibiting symptoms of shunt infection leaving a total of 54 for analysis. All the patients included in the study were followed up for six months. Their mean ages were between 1688.5 ± 665.3 (days) for Vancomycin group and 10,222 ± 6635.8 (days) for Gentamicin group. There was male preponderance of 55.6% as against female of 44.4%. Majority of the hydrocephalus were of congenital cause accounting for 64.8%. There was one shunt infection in the Gentamicin group giving rise to an infection rate of 1.9% which was not statistically significant (P –value—0.313). The organism isolated was Pseudomonas species.ConclusionVentriculoperitoneal shunt infection rates can be reduced to the barest minimum if standard concentration of antibiotics is used to prepare the shunt hardware employing a standard surgical technique.

Development of Protocol for Ventriculoperitoneal Shunt Surgery in Paediatric Patients to Reduce Shunt Infection

Background: Ventriculoperitoneal shunt (VPS) is the most common treatment modality for hydrocephalus. However, VPS infection is acommon and serious complication with high rates of mortality and morbidity and there is some emerging evidence suggesting that adherence to a strict protocol may be important in reducing the rate of shunt infection. Objectives: To develop a protocol for initial ventriculoperitoneal shunt surgery and assess the efficacy of this protocol in reducing ventriculoperitoneal shunt infection rate. Materials and Methods: This study was a comparative study was carried out in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from December 2021 to March 2023. Total 100 patients were included in this study. Patients &lt; 18 years of age undergoing initial ventriculoperitoneal shunt surgery for hydrocephalus due to various etiologies in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University. Data collection sheet was used to collect the necessary information. Voluntary written informed consent was taken from the patients and/or the legal guardian/responsible family members after completely explaining to them the procedure and the purpose of the study. Using simple random sampling by lottery method, the patients were divided into a study group and a control group. Patients in the study group underwent ventriculoperitoneal shunt surgery as per the proposed surgery protocol and strict adherence to the protocol by the operating surgeon was ensured. Patients in the control group underwent ventriculoperitoneal shunt surgery as per the current standard practice. Post-operative care of the patient was carried out as per the standard practice in both the groups. Follow-up of the patients were done on an outpatient department basis at 1 month and at 3 months postoperatively, where they were examined thoroughly for signs and symptoms of shunt infection. Patients not showing up at the outpatient department were ...

Long-Term Complications and Treatment in Patients with Ventriculo-Peritoneal Shunt Surgery

The purpose of treatment hydrocephalus is to maintain intracranial pressure, as well as to create a favorable psychomotor developmental environment, particularly in pediatric cases. Various complications associated with shunt surgery require long-term care. When a shunt is performed for neonates and infants with hydrocephalus, proper management is required thereafter during whole their life. The most common complication that can occur as a result of shunt surgery is obstruction of the ventricular catheter. Ventricular catheter obstruction can be avoided by placing that the tip of the catheter is placed in an appropriate position. A further measure would include preventing the ventricular catheter from being pulled out as the skull expands. The next common complication is obstruction of the peritoneal catheter. The risk of occlusion can be reduced by making that the tip of the peritoneal catheter is open-ended as opposed to having side slits. Isolated ventricles and slit ventricle syndrome are peculiar shunt-related conditions that are difficult to treat. When shunt dysfunction occurs, hydrocephalus can progress slowly, but in many cases the patient's condition deteriorates rapidly and requires immediate medical intervention. Recently, neuroendoscopic surgery has been actively performed for cases of shunt dysfunction and prophylactic replacement of peritoneal catheters, and attempts have been made to remove the shunt device. Shunt infection is another troublesome complication in the management of hydrocephalus and has not yet been resolved. However, if all staff involved in shunt surgery have a common understanding and adopt fixed protocols related to preoperative, intraoperative, and postoperative management, the incidence of infection can be significantly reduced. Furthermore, the development of new and improved catheters may also contribute to a reduction in shunt infection. Neurosurgeons should be cognizant that a delay in the diagnosis and treatment of shunt-related complications in patients with hydrocephalus could result in death. Shunt surgery for the treatment of pediatric hydrocephalus is merely the beginning, as neurosurgeons must be responsible for management until the child reaches adulthood.

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.

Ventriculoperitoneal shunt infections in children; 10 years of experience in a single center

Objective: Shunt infections are a serious health problem seen in children. Our aim in this study is to investigate the clinical features, bacterial pathogens and antimicrobial treatments of pediatric patients with ventriculoperitoneal shunt infection.&#x0D; Methods: This retrospective study included 108 pediatric patients with ventriculoperitoneal shunt infection who were followed up in the Pediatric Infection Clinic of Dicle University Medical Faculty between January 2019 and December 2019.&#x0D; Results: The cases were 48.1% male and 51.9% female. Ventriculoperitoneal were placed in 70.4% of the cases when they were 0-1 months old, and in 15.7% of the cases when they were 2-3 months old. The most common cause of ventriculoperitoneal shunt implantation was congenital hydrocephalus (90.7%), followed by central nervous system tumors (5.6%) and central nervous system infections (2.8%). The most common clinical signs and symptoms were fever (91.7%), vomiting (87%), convulsion (49.1%), change of consciousness (50.9%), meninx irritation finding (37.0%), anterior fontanelle cuff (65.7%), shunt leak (57.4%) and abdominal symptoms (62%). The most frequently isolated pathogens from cerebrospinal fluid cultures were Coagulase negative staphylococcus (36.1%), Staphylococcus aureus (14.8%), Klebsiella pneumoniae (13%), Pseudomonas aeruginosa (6.5%), Acinetobacter baumannii (16%,) and Escherichia coli (11.1%). The most commonly used antibiotics in treatments were vancomycin (68.5%), meropenem (67.5%), ceftriaxone (45.3%), colimycin (26.8%), amikacin (25%), linezolid (21.2%) and cephotaxime (9.2%). The mortality rate of the patients was 20.4%.&#x0D; Conclusions: Knowing the risk factors and taking early precautions in ventriculoperitoneal shunt infections can significantly reduce shunt infections, and better results can be obtained by determining the possible pathogens and starting empirical treatment accordingly.

Topical instillation of vancomycin lowers the rate of CSF shunt infections in children.

Shunt surgery in pediatric patients still bears a significant risk of infection, in addition to mechanical complications of the shunt system. Antibiotic-impregnated systems and perioperative antibiotics have been extensively studied for their potential to reduce shunt infections. We examined the effectiveness of intrawound application of vancomycin powder during shunt surgery. Patient records of 78 primary shunt implantations at a mean age of 40months were reviewed. In total, 52 patients (mean age 50months) had been treated according to standard surgical and perioperative procedures (Std), whereas 26 patients (mean age 20months) additionally had received topical application of vancomycin powder before wound closure (Vmc). Overall infection rate was 3.8%, in Std patients 5.8%, and in Vmc patients 0%. The rates of CSF fistula and revision surgery were similar in both groups (5.8% vs 8% and 23.1% vs. 30%, respectively). To the best of our knowledge, this is the first report on topical vancomycin instillation, indicating its efficacy for the prevention of shunt infection in pediatric patients. Further studies with a higher number of patients are needed to verify this finding.

Calgary Shunt Protocol, an adaptation of the Hydrocephalus Clinical Research Network shunt protocol, reduces shunt infections in children.

The shunt protocol developed by the Hydrocephalus Clinical Research Network (HCRN) was shown to significantly reduce shunt infections in children. However, its effectiveness had not been validated in a non-HCRN, small- to medium-volume pediatric neurosurgery center. The present study evaluated whether the 9-step Calgary Shunt Protocol, closely adapted from the HCRN shunt protocol, reduced shunt infections in children. The Calgary Shunt Protocol was prospectively applied at Alberta Children's Hospital from May 23, 2013, to all children undergoing any shunt procedure. The control cohort consisted of children undergoing shunt surgery between January 1, 2009, and the implementation of the Calgary Shunt Protocol. The primary outcome was the strict HCRN definition of shunt infection. Univariate analyses of the protocol, individual elements within, and known confounders were performed using Student t-test for measured variables and chi-square tests for categorical variables. Multivariable logistic regression was performed using stepwise analysis. Two-hundred sixty-eight shunt procedures were performed. The median age of patients was 14 months (IQR 3-61), and 148 (55.2%) were male. There was a significant absolute risk reduction of 10.0% (95% CI 3.9%-15.9%) in shunt infections (12.7% vs 2.7%, p = 0.004) after implementation of the Calgary Shunt Protocol. In univariate analyses, chlorhexidine was associated with fewer shunt infections than iodine-based skin preparation solution (4.1% vs 12.3%, p = 0.02). Waiting ≥ 20 minutes between receiving preoperative antibiotics and skin incision was also associated with a reduction in shunt infection (4.5% vs 14.2%, p = 0.007). In the multivariable analysis, only the overall protocol independently reduced shunt infections (OR 0.19 [95% CI 0.06-0.67], p = 0.009), while age, etiology, procedure type, ventricular catheter type, skin preparation solution, and time from preoperative antibiotics to skin incision were not significant. This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small- to medium-volume pediatric neurosurgery setting. Implementation of the Calgary Shunt Protocol independently reduced shunt infection risk. Chlorhexidine skin preparation and waiting ≥ 20 minutes between administration of preoperative antibiotic and skin incision may have contributed to the protocol's quality improvement success.

C.07 Calgary shunt protocol, an adaptation of the hydrocephalus clinical research network shunt protocol reduces risk of shunt infection in children

Background: The effectiveness of the Hydrocephalus Research Network (HCRN) shunt protocol has not been validated in a non-HCRN, small-to-medium volume pediatric neurosurgery center. This study evaluates whether the 9-step Calgary Shunt Protocol (CSP) adapted from the HCRN shunt protocol reduced shunt infections. Methods: The CSP was prospectively applied at Alberta Children’s Hospital from May 23rd, 2013 to all children undergoing any shunt procedure. Children undergoing shunt surgery before CSP implementation acted as a control-cohort. The strict HCRN definition of shunt infection was applied. Results: A total of 268 shunt procedures were performed. There was a significant absolute risk reduction of 10.0% ([95%CI 3.9%-15.9%], p=0.004) in shunt infections after implementation of the CSP. In univariate analyses, chlorhexidine compared to povidone skin prep reduced shunt infection by 8.2% ([95%CI 1.84-14.6%], p=0.02) and waiting ≥ 20 min between receiving preoperative antibiotics and skin incision reduced shunt infections by 9.6% ([95%CI 2.4%-16.9%], p=0.02). In multivariate analysis, only protocol implementation independently reduced shunt infections (OR 0.19 [95%CI 0.06-0.67], p=0.004). Conclusions: This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small-to-medium volume neurosurgery setting. Chlorhexidine skin prep and waiting ≥ 20 min between preoperative antibiotic and skin incision may have contributed to the protocol’s quality improvement success.

Prevention of infection by antibiotic-impregnated shunts after pediatric hydrocephalus treatment: A single center, retrospective study in China

ObjectiveTo investigate infection prevention by antibiotic-impregnated shunts (AIS) relative to conventional ones after pediatric hydrocephalus treatment. MethodsThis single center, retrospective analysis comprised 807 consecutive pediatric cases of hydrocephalus shunting performed by the same neurosurgeon between January 2001 and February 2013. Conventional and AIS catheters were used in 303 and 504 cases, respectively. Study outcomes were infection rates at 6 months (primary), and at 1 month and between 1 and 6 months (secondary). An infant (<1year) subgroup was also analyzed. ResultsThe AIS relative to the conventional catheter group had significantly lower infection rates at 6 months (1.98% [10/504] vs. 5.95% [18/303], two-tailed p=0.0046; central nervous system: 60% and 55.56%; abdominal: 20% and 27.77%; wound: 20% and 16.67%, respectively) and 1 month (0.19% [1/504] vs. 2.65% [8/303], p=0.0023, respectively), but statistically similar rates between 1 and 6 months (1.79% [9/504] vs. 3.30% [10/303], p=0.2296, respectively). In the infant subgroup, AIS application was also associated with reduction in shunt infection (1.49% [7/470] vs. 3.76% [10/266], p=0.0489, respectively). ConclusionAIS as compared to conventional catheter use appears to lower infection risk at 6 months, mainly during the first month, after hydrocephalus therapy in children.

A Study to Formulate a Strategy to Prevent Ventriculoperitoneal Shunt Infection

Aim This study aims to formulate a least expensive yet effective and simple surgical strategy for prevention of ventriculoperitoneal shunt infections. Patients and Methods This study was done prospectively in 486 cases admitted during the period from 2006 to 2013. Patients were divided into two groups and a protocol was devised to reduce shunt infections. In group 1, the shunt was done following the protocol and the other group, protocol was not followed. The various factors contributing to shunt infection were analyzed in detail and its statistical significance worked out. Results The group 1 where protocol is followed showed 0% incidence of shunt infection. In the group, where the protocol was not followed, it is observed that prolonged surgery, use of intermediate skin incision, and previous shunt surgery contribute to increased risk of shunt infection.

Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants.

The incidence of ventriculoperitoneal (VP) shunt infection accounts for about 5-15%, but it can rise up to 70% in specific high-risk subgroups. Antibiotic-impregnated catheters (AICs) have been designed to reduce shunt infections, but reports on their efficacy are discordant, especially in young children. The aim of this study is to assess, for the first time, the efficacy of AICs in newborns and infants at very high risk for shunt infection. We reviewed the medical records of newborns and infants treated with a VP shunt for newly diagnosed hydrocephalus. Patients were divided in two groups: Group A was composed by children who received AICs, whereas Group B included children implanted with standard silicone catheters (non-AICs). We compared the shunt infection rate in both groups, and analyzed differences in specific high-risk subgroups (preterm newborns, children with posthemorrhagic or postinfective hydrocephalus, and children with a previous external ventricular drainage). Forty eight children younger than 1 year old were included in our study. Twenty two patients were implanted with an AIC, whereas 26 patients received a standard silicone catheter. The follow-up was at least 1 year (mean 8 ± 3 years). The overall infection rate decreased from 34% in non-AIC group to 9 % in the AIC group. Moreover, AICs showed to have a protective effect against shunt infections in all the specific high-risk subgroups analyzed. This study demonstrates for the first time that AICs are effective in reducing VP shunt infection in high-risk pediatric patients younger than 1 year old.

Evidence-based interventions to reduce shunt infections: a systematic review.

Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence. A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included. Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates. Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.

Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants.

Intraventricular hemorrhage in premature infants often leads to progressive ventricular dilation and the need for ventricular reservoir placement. Unfortunately, these reservoirs have a higher rate of infection than ventriculoperitoneal shunts in premature babies. The authors analyzed the risk factors for infection in this population and studied whether the implementation of an institutional protocol for shunt placement had a corollary effect on ventricular access device (VAD) infection rates in premature neonates with intraventricular hemorrhage. The authors conducted a retrospective cohort review of consecutive premature neonates in whom VADs were inserted in the operating room at Primary Children's Hospital between June 2003 and June 2011 to identify risk factors for infection. Medical records were reviewed for information on infection (culture proven or eroded hardware at 90 days), gestational age at birth, weight, gestational age at surgery, intrathecal antibiotics, hemorrhage, death, and surgeon. The institution used a pilot protocol for shunt infection reduction in 2006-2007, and then the full Hydrocephalus Clinical Research Network protocol from June 2007 to 2011, and the rates of infection during these periods were analyzed. Confounding factors such as sepsis, necrotizing enterocolitis, and a history of meningitis were also analyzed. The overall infection rate was 10.5% (11 patients) in the 105 patients identified. Gestational age at procedure was a significant risk factor for infection (p=0.05). Meningitis was significantly associated with infection, with 63% of the infected group having had prior meningitis compared with 7% for the noninfected group (p<0.001). Concurrent with the implementation of the protocol to reduce shunt infection, the VAD infection rate decreased from 14.7% to 5.4% (p=0.2). Gestational age at procedure and previous meningitis were significant risk factors for VAD infections. In addition, the implementation of an institutional standardized shunt protocol for ventriculoperitoneal shunts may have altered the operating room team's behavior, indicated by a nonmandated use of intrathecal antibiotics in VAD surgeries, contributing to a reduced VAD infection rate. Although the observed difference was not statistically significant with the small sample size, the authors believe that these findings deserve further study.

Response to validity of the results of a perioperative protocol to reduce shunt infections

Comment to Dr. Kshettry We thank Dr. Varun R Kshettry for comments on our article “Significant reduction of shunt infection rate in children below 1 year of age after implementation of a perioperative protocol”. The impact of using antibiotic-impregnated shunt (AIS) catheters is relevant, and something we considered during the statistical analyses of the material. While the AIS catheters were used at the discretion of the treating physician, a number of surgeons were performing the shunt operations. During the study period, the department had not implemented a strict protocol on the use of AIS catheters. The decision to use an AIS catheter was subjective to the surgeon. Hence, the AIS catheters were not used exclusively in the high-risk population. Based on our available information, we cannot conclude that the use of AIS catheters made a systematic impact, or that those receiving AIS catheters were more at risk for infection. Accordingly, while Dr. Kshettry makes an important comment regarding the use of AIS catheters, we have no reason to believe that this aspect significantly affects the conclusions of our work. Nevertheless, in a continued effort to reduce shunt infection rate, we recommend more extensive use of AIS catheters together with better protocol compliance.

Letter to the Editor: Validity of the results of a perioperative protocol to reduce shunt infections

Dear Editor, I read with interest the article by Hommelstad et al. demonstrating a reduction in shunt infection rates, primarily in children below 1 year of age, after implementation of a perioperative protocol [1]. I would like to highlight a potential limitation in the study methodology that could significantly impact the interpretation of the efficacy of their perioperative protocol. Although not listed as part of the protocol, the authors state that in the post-protocol cohort, antibiotic-impregnated shunt (AIS) catheters were used at the discretion of the treating physician. AIS catheters were used in 200 (21.6 %) of the procedures post-protocol compared to zero in the pre-protocol cohort. In patients less than 1 year in age, 52 % received an AIS catheter post-protocol. AIS catheters were selectively used in patients considered to be at high risk for shunt infection. The authors state that there was no significant difference in infection rate between the 200 AIS catheter operations compared to the 727 non-AIS catheter operations (p=0.935). In patients less than 1 year of age, there was also no statistically significant difference in infection rate between AIS and non-AIS operations, although with a lower p-value (0.179). The authors interpret this finding to indicate that AIS catheters did not contribute significantly to the reduction in shunt infection in the post-protocol cohort. However, the selection bias in this statistical comparisonmust not be overlooked. One would expect a significantly higher infection rate in the highrisk population, so the finding that a high-risk population receiving AIS catheters had a similar infection rate to a lowrisk population receiving non-AIS catheters should be interpreted as possible evidence that AIS catheters resulted in a reduction of shunt infection. In the pediatric population, a recent meta-analysis revealed that shunt infection occurred in 11.2 % of non-AIS versus 5.0 % of AIS catheter procedures [2]. In the trial by Hommelstad et al., the use of AIS catheters in patients deemed to be at high risk should be considered as part of the new protocol introduced by the authors. As a result, the true effect of the perioperative protocol in the absence of AIS catheters remains uncertain.

Effectiveness of the Bactiseal Universal Shunt for reducing shunt infection in a sub-Saharan African context: a retrospective cohort study in 160 Ugandan children

Antibiotic-impregnated shunts have yet to find widespread use in the developing world, largely due to cost. Given potential differences in the microbial spectrum, their effectiveness in preventing shunt infection for populations in low-income countries may differ and has not been demonstrated. This study is the first to compare the efficacy of a Bactiseal shunt system with a non-antibiotic-impregnated system in a developing country. The Bactiseal Universal Shunt (BUS) was placed in 80 consecutive Ugandan children who required a shunt. In this retrospective cohort study, the outcome for that group was compared with the outcome for the immediately preceding 80 consecutive children in whom a Chhabra shunt had been placed. The primary end points were shunt failure, shunt infection, and death. Shunt survival was analyzed using the Kaplan-Meier method. Significance of differences between groups was tested using the log-rank test, chi-square analysis, Fisher's exact test, and t-test. There was no difference between groups in regard to age, sex, or etiology of hydrocephalus. Mean follow-up for cases of nonfailure was 7.6 months (median 7.8 months, interquartile range 6.5-9.5 months). There was no significant difference between groups for any end point. The BUS group had fewer infections (4 vs 11), but the difference was not significant (p = 0.086, log-rank test). Gram-positive cocci were the most common culturable pathogens in the Chhabra group, while the only positive culture in the BUS group was a gram-negative rod. These results provide equipoise for a randomized controlled trial in the same population and this has been initiated. It is possible that the observed trends may become significant in a larger study. The more complex task will involve determining not only the efficacy, but also the cost-effectiveness of using antibiotic-impregnated shunt components in limited-resource settings.

Significant reduction of shunt infection rate in children below 1 year of age after implementation of a perioperative protocol

Shunt infection markedly impairs the clinical result of shunt surgery. The infection rate can be reduced by dedicated protocols. This study was undertaken to determine the efficacy of introducing a perioperative protocol for control of shunt infections. The shunt infection rate and risk factors for shunt infection were determined for two periods, namely the period 2001-2002 (Patient Material A), and the period 2005-2008 (Patient Material B). The perioperative protocol was introduced in 2005 before the second period. The total patient material includes 901 patients, in whom 1,404 shunt procedures were performed during the study periods. While the overall infection rate dropped nonsignificantly from 6.5 % to 4.3 %, infection rate dropped markedly and significantly from 18.4 % to 5.7 % among the children younger than 1 year (p = 0.016). The significant risk factors for shunt infection were in Patient Material A age below 1 year (p < .001), and in Patient Material B premature birth (p = 0.045), postoperative cerebrospinal fluid (CSF) leakage (p < .001) and high American Society of Anaesthesiologists (ASA) score (p = 0.039). Of the protocol steps, only the lack of preoperative wash with 4 % clorhexidine gluconate (Hibiscrub®) showed a tendency of influencing the shunt infection rate (p = 0.051). This study showed that implementation of a perioperative protocol markedly and significantly reduced shunt infection rate in children younger than 1 year, even though no significant overall reduction in shunt infection rate was found.

Cerebrospinal shunt infection in patients receiving antibiotic-impregnated versus standard shunts

Cerebrospinal fluid shunt infections are associated with significant morbidity and mortality in the treatment of adult and pediatric hydrocephalus. Antibiotic-impregnated shunt (AIS) catheters have been used with the aim of reducing shunt infection. While many studies have demonstrated a reduction in shunt infection with AIS, this reported efficacy has varied within the literature. The authors performed a systematic literature review to identify all published articles comparing the incidence of CSF shunt infection in AIS versus non-AIS catheters. The incidence of infection for AIS versus non-AIS catheters was calculated using the Mantel-Haenszel common odds ratio, and baseline demographics were compared between AIS and non-AIS cohorts. Twelve AIS versus non-AIS cohort comparisons were identified in the literature (5 pediatric hydrocephalus, 3 adult hydrocephalus, and 4 mixed populations). In a total of 5613 reported shunt procedures (2664 AISs vs 2949 non-AISs), AISs were associated with a reduction in shunt infection (3.3% vs 7.2%; OR 0.439, p < 0.0001). In 787 shunt procedures for adult hydrocephalus (427 AIS vs 360 non-AIS), AISs were associated with reduction in shunt infection (0.9% vs 5.8%; OR 0.153, p < 0.0001). In 1649 shunt procedures for pediatric hydrocephalus (854 AIS vs 795 non-AIS), AISs were associated with reduction in shunt infection (5.0% vs 11.2%; OR 0.421, p < 0.0001). The authors' systematic review of the literature demonstrates that AIS catheters are associated with a significant reduction over non-AIS catheters in the reported incidence of CSF shunt infection in adult and pediatric populations. The AIS catheters do not appear to be associated with an increased incidence of antibiotic-resistant microorganisms. Prospective, randomized trials are needed to firmly assess and confirm this apparent difference in infection incidence.

Editorial: Pooling data on antibiotic-impregnated shunts

In this issue of the Journal of Neurosurgery: Pediat­ rics, Dr. Parker and colleagues summarize the literature on antibiotic impregnated shunts (AISs). Using a systematic literature review, they identify 12 cohorts that directly compare AISs versus non-AISs. Five of these are for pediatric hydrocephalus, 3 for adult hydrocephalus, and 4 included mixed populations. They have identified a large number of shunt procedures (5613) and report a reduction in shunt infection using AIS catheters in the entire study and separately in pediatric and adult subpopulations.6 At first glance, these are impressive data. The large number of shunt procedures and the reduced infection rates seem to support the efficacy of AISs. The methods of the systematic review are well done, but there is room for improvement before we accept the conclusions. A well-done systematic review of high-quality randomized trials is one of our best sources of evidence for making treatment decisions. There is extensive literature on the methods used to produce a high-quality systematic review. I will refer to the main points in discussing Dr. Parker’s work.