Use Of Antibiotic-impregnated Catheters Research Articles

A standardized infection prevention bundle for reduction of CSF shunt infections in adult ventriculoperitoneal shunt surgery performed without antibiotic-impregnated catheters.

Ventriculoperitoneal (VP) shunt insertion and revision surgeries are some of the most common procedures that are performed by neurosurgeons. Shunt infections within the adult population are associated with significant morbidity and mortality and rates remain high. The objective of the current study was to use quality improvement (QI) methodology to create a standardized infection prevention bundle aimed at reducing the rate of shunt infections. A prospective, single-center, single-surgeon QI study was undertaken. Patients were included if they were 18 years of age or older and were undergoing a VP shunt insertion or revision. The primary outcome of the study was the development of a shunt-related surgical site infection, within 1 year of surgery, as defined according to the Canadian Nosocomial Infection Surveillance Program guidelines. There was no standardized protocol prior to July 2013. A bundle coined as the Calgary Adult Shunt Infection Prevention Protocol (CASIPP) was implemented on July 1, 2013, and updated on July 1, 2015, when 2% chlorhexidine gluconate in 70% isopropyl alcohol replaced povidone-iodine for preoperative skin antisepsis. Protocol compliance was regularly monitored using a standardized process. No antibiotic-impregnated catheters were used. A total of 621 consecutive VP shunt insertions and revisions were included in the study. The rate of shunt infection was 5.8% during the period in which there was no standardized shunt protocol. After the implementation of the CASIPP the infection rate decreased to 4.0%, and after introduction of the chlorhexidine/alcohol skin antisepsis, the infection rate was 0% in 379 consecutive procedures (p < 0.0001). Multivariable logistic regression analysis demonstrated that the use of chlorhexidine/alcohol with CASIPP was associated with a significant reduction in the odds of developing a shunt infection (OR 0.032, 95% CI 0-0.19, p = 0.0005). The implementation of a standardized shunt infection prevention bundle within the adult population, without the use of antibiotic-impregnated catheters, significantly reduced the rate of shunt infections which was sustained over many years. The use of 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis may have played a significant role. Multicenter studies should be completed to verify the effectiveness of the authors' protocol.

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.

The Hydrocephalus Clinical Research Network quality improvement initiative: the role of antibiotic-impregnated catheters and vancomycin wound irrigation.

Two previous Hydrocephalus Clinical Research Network (HCRN) studies have demonstrated that compliance with a standardized CSF shunt infection protocol reduces shunt infections. In this third iteration, a simplified protocol consisting of 5 steps was implemented. This analysis provides an updated evaluation of protocol compliance and evaluates modifiable shunt infection risk factors. The new simplified protocol was implemented at HCRN centers on November 1, 2016, for all shunt procedures, excluding external ventricular drains, ventricular reservoirs, and subgaleal shunts. Procedures performed through December 31, 2019, were included (38 months). Compliance with the protocol, use of antibiotic-impregnated catheters (AICs), and other variables of interest were collected at the index operation. Outcome events for a minimum of 6 months postoperatively were recorded. The definition of infection was unchanged from the authors' previous report. A total of 4913 procedures were performed at 13 HCRN centers. The overall infection rate was 5.1%. Surgeons were compliant with all 5 steps of the protocol in 79.4% of procedures. The infection rate for the protocol alone was 8.1% and dropped to 4.9% when AICs were added. Multivariate analysis identified having ≥ 2 complex chronic conditions (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.26-2.44, p = 0.01) and a history of prior shunt surgery within 12 weeks (OR 1.84, 95% CI 1.37-2.47, p < 0.01) as independent risk factors for shunt infection. The use of AICs (OR 0.70, 95% CI 0.50-0.97, p = 0.05) and vancomycin irrigation (OR 0.36, 95% CI 0.21-0.62, p < 0.01) were identified as independent factors protective against shunt infection. The authors report the third iteration of their quality improvement protocol to reduce the risk of shunt infection. Compliance with the protocol was high. These updated data suggest that the incorporation of AICs is an important, modifiable infection prevention measure. Vancomycin irrigation was also identified as a protective factor but requires further study to better understand its role in preventing shunt infection.

Intraoperative Injection of Intraventricular Antibiotics is Associated With a Decreased Incidence of Infection and Revision Surgery in Pediatric Hydrocephalus Patients Undergoing Shunt Placement

Abstract INTRODUCTION Infection is the most common cause of morbidity and additional intervention following the placement of a ventriculoperitoneal shunt, even with the use of antibiotic-impregnated catheters. At present, no studies have demonstrated the utility of intraoperative, intraventricular antibiotic injection in reducing the rates of infection and shunt revision. METHODS A prospective, multicenter, shunt-specific neurosurgical registry was used to identify all pediatric patients undergoing first-time placement of a shunt for the definitive treatment of hydrocephalus. All patients who received intraventricular antibiotics (eg, vancomycin or gentamicin) via the shunt catheter during surgery were identified. A variety of variables, including prior temporizing measures (ventriculostomy, subgaleal shunt, reservoir, etc), use of surgical adjuncts (antibiotic-impregnated catheter, stereotactic guidance, choroid plexus coagulation), and reasons for unplanned interventions (infection, CSF leak, catheter obstruction) were collected for each patient. Bivariate statistics and multivariable regression modeling were used to explore the relationship between prophylactic, intraventricular antibiotic placement and subsequent outcomes. RESULTS A total of 2193 pediatric patients undergoing shunt placement for hydrocephalus were identified. Of these, 552 (25.2%) underwent intraoperative injection of antibiotics into the ventricular space. Postoperatively, 104 (4.7%) patients had unplanned removal, replacement, or revision of their shunt at a mean of 14.2 +/− 9 d following the initial procedure. A total of 29 (27.9%) of these interventions were secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, use of image guidance, and placement of an antibiotic-impregnated shunt, intraoperative injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (OR = 0.217, 95% CI: 0.051–0.916, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.36%) went on to develop an infection. CONCLUSION Pediatric patients who received prophylactic, intraoperative injection of intraventricular antibiotics experienced a significantly decreased incidence of additional surgery secondary to infection, even when controlling for the use of antibiotic-impregnated catheters.

P104 One year failure rates for de novo ventriculo-peritonealshunts in under 3- month-old children

ObjectivesHistorically VPS failure and infection rates are higher for neonates than for older children. We compared our one year VPS failure and infection rates in under 3-month-olds with those of older children.DesignA retrospective, single centre study comparing 1 year survival and infection rates of VPS in under 3-month-olds verses older children.Subjects58 children under 3 months of age underwent VPS insertion between January 2007 and December 2016.MethodsData was collected by three independent reviewers from electronic files and case notes. Data was analysed using descriptive statistics and one year shunt survival curves were produced.ResultsFor children under 3 months there was a 29.3% one-year shunt failure rate, of which 2 were shunt infections (3.4%). In patients greater than 3 months, the shunt malfunction rate was 23.4% and the infection rate was 4.3%. There were no shunt-related mortalities in either group.ConclusionsChildren under 3-months-old undergoing VPS insertion should not automatically expect an increased 1 year failure or infection rate compared with older children. Reasons for this may be increased sub-specialisation, improved neonatal care and use of antibiotic impregnated catheters.

One year failure rates for de-novo ventriculo-peritoneal shunts in under 3-month-old children

Introduction: Ventriculo-peritoneal shunts (VPS) are still the mainstay treatment for hydrocephalus in children. It is generally accepted that VPS failure and infection rates are higher for neonates than for older children. We compared our 1-year failure and infection rates in under 3-month-old children compared with older children in our department.Results: We identified 58 children under 3 months of age who underwent VPS insertion between January 2007 and December 2016. They had a 29.3% (17) shunt failure rate over the first year. There were two confirmed shunt infections (3.4%).Discussion: The 1-year shunt failure rate at our institution for VPS insertion in children over 3 months is 26.1% and the infection rate is 4.3% (9). The literature suggests that the outcome for VPS in younger children is worse than for older children. Our work shows similar outcomes for all children compared to those under 3 months at time of VPS insertion alone.Conclusion: Children under 3-months-old undergoing VPS insertion should not automatically expect an increased 1-year failure or infection rate compared with older children. The reasons for this may be as a result of increased subspecialisation, the more widespread use of antibiotic-impregnated catheters and improved neonatal care.

PMD29 - Economic impact derived from the use of a catheter impregnated with Antibiotic in pediatric patients with hydrocephalus treated with external shunts in Mexico

Estimate the economic impact derived from the use of antibiotic-impregnated catheters vs. traditional, non-antibiotic-impregnated catheters for the treatment of hydrocephalus in pediatric patients with external shunts from a Mexican public hospital perspective (IMSS). An Excel-based decision tree was used to estimate the economic consequences of using an antibiotic-impregnated catheter (treatment group) vs. a catheter without antibiotic (control group) for target population. Given procedure volume variability in comparable hospitals, base-case scenario assumed 100 pediatric patients with hydrocephalus and only one potential infection after first catheter placement; the antibiotic-impregnated device was assumed as second-line treatment for both groups. Infection rates after catheter placement for considered alternatives were taken from published international meta-analyses (2.4% vs. 8.7% for treatment and control groups, respectively). Unitary costs were provided by internal resources (antibiotic-impregnated device) and by public bid results for base-case hospital (traditional catheter). Considered time horizon was <1 year, thus no annual discount rate for costs was necessary. Inflation-adjusted DRGs from IMSS´s high specialty hospitals were used as hospitalization (catheter placement) and catheter replacement costs. Results are shown in 2015-adjusted USD. Due to low reinfection rates documented in literature, posterior infections and mortality were not considered. The total cost of the catheter with antibiotic strategy resulted in $1,610,600, while the non-antibiotic catheter strategy in $1,542,200, resulting in additional $684 per patient treated with the antibiotic-impregnated device and $11,400 per avoided infection. The use of antibiotic-impregnated catheters appears to be a cost-effective alternative to treat hydrocephalus in pediatric patients in the Mexican setting. Local high-specialty hospitals should consider the adoption of this alternative as it yields less infections in target population.

Infection and Hemodialysis Access: An Updated Review.

The incidence of end-stage renal disease (ESRD) has almost doubled over past 2 decades. Despite decreasing overall hospital admission rates for ESRD population, the rate of infection-related hospitalizations has steadily increased. Infection remains the second most common cause of mortality in this patient population. Specifically, in the hemodialysis (HD) patients, the vascular access related infections are the most common identifiable source of infection. This concise review provides an update on the bacteremia related to vascular access primarily the catheters (Catheter Related Blood Stream Infection- CRBSI) in HD patients emphasizing on the determinants ranging from the epidemiology to pathogenesis, risk factors, cost implications and prevention. Staphylococcus aureus, coagulase negative Staphylococci, and Enterococci are the most common causative microorganisms implicated in CRBSI. The pathogenesis of CRBSI includes organism entry into the blood stream followed by adherence to catheter, colonization and biofilm formation. Vascular access type, catheter position, and prior bacteremic episodes are strongly associated with blood stream infection. Preventive measures should be multidisciplinary in nature and should include avoidance of central venous catheters, best practices for catheter care, surveillance, antimicrobial catheter lock solutions, and use of antibiotic impregnated catheters.

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 &gt;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.

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.

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.

Comparison of Two Antibiotic-Impregnated Ventricular Catheters: A Prospective Sequential Series Trial

External ventricular drains (EVDs) are valuable adjuncts in the management of neurosurgical patients but are associated with a significant risk of cerebrospinal fluid (CSF) infection (range, 0% to 27%); a review of 23 studies reported a mean of 8.8%. To compare the efficacy of 2 different antibiotic-impregnated EVD catheters in preventing CSF infections. Patients were prospectively enrolled in an Institutional Review Board-approved study. During alternating 3-month periods, all patients received either a minocycline/rifampin-impregnated (M/R) ventricular catheter or a clindamycin/rifampin-impregnated (C/R) EVD catheter. CSF cultures were collected at the time of insertion and twice weekly. Positive cultures were defined a priori as growth of the same bacteria on 2 media (eg, blood agar and broth) or 2 cultures of the same bacteria on 1 medium (eg, broth). Altogether, 129 patients (mean age, 58.4 years; 55 male) received 65 C/R catheters and 64 M/R catheters. The most common indications for EVD placement were aneurysmal subarachnoid hemorrhage (48.1%), spontaneous intraparenchymal hemorrhage (13.2%), and tumor (11.6%). The mean duration of ventriculostomy drainage was 11.8 and 12.7 days in the C/R and M/R groups, respectively. No positive CSF cultures were identified in either cohort. The use of antibiotic-impregnated catheters was associated with an extremely low risk of CSF infection compared with the reported mean of nearly 9% for standard EVD catheters. Infection rates for both C/R and M/R EVD catheters were zero. These results support the use of antibiotic-impregnated EVD catheters in routine clinical practice.

Clinical effectiveness and risk of emerging resistance associated with prolonged use of antibiotic-impregnated catheters: More than 0.5 million catheter days and 7 years of clinical experience*

Catheters coated with minocycline and rifampin are proven to decrease the rates of central line-associated bloodstream infection; however, it is unclear whether success occurs independent of other infection control precautions. We evaluated the effect of catheters coated with minocycline and rifampin with and without other infection control precautions on our rates of central line-associated bloodstream infection in critically ill patients and on antibiotic resistance throughout the hospital and in the intensive care unit. Retrospective clinical cohort study conducted during 1999-2006 with an observational laboratory component. A tertiary university-based cancer center. All 8009 patients admitted to the medical intensive care unit were subjects for the surveillance of central line-associated bloodstream infection. All Staphylococcus aureus and coagulase-negative staphylococci clinical isolates cultured at our institution during the same period were subjects for laboratory testing. Using catheters coated with minocycline and rifampin and implementing infection control precautions. Incidence of central line-associated bloodstream infection in the medical intensive care unit. Change in resistance to tetracycline and rifampin in clinically relevant staphylococcal isolates in the intensive care unit and hospitalwide. During the study period, 9200 catheters coated with minocycline and rifampin were used hospitalwide over a total of 511,520 catheter days. The incidence of central line-associated bloodstream infection per 1000 patient days in the medical intensive care unit significantly and gradually decreased from 8.3 in 1998 to 1.2 in 2006 (p ≤ .001). The resistance of S. aureus and coagulase negative staphylococci clinical isolates to tetracycline or rifampin in the intensive care unit and on a hospitalwide level remained stable or decreased significantly during the same period. Catheters coated with minocycline and rifampin significantly decreased the incidence of central line-associated bloodstream infection in the medical intensive care unit in a manner that was independent and complementary to the infection control precautions. Although this study strongly suggests an association between catheters coated with minocycline and rifampin use and a decrease in central line-associated bloodstream infection, because of multiple other concurrent interventions, the results should be interpreted cautiously until a prospective study is conducted. Furthermore, long-term use of these devices is not associated with increased resistance of staphylococcal isolates to tetracycline and rifampin in the intensive care unit or throughout the hospital.

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.

Impact of a standardized protocol and antibiotic-impregnated catheters on ventriculostomy infection rates in cerebrovascular patients.

Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters. To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters. Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5). The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5). The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

Efecto de los catéteres impregnados con antibiótico en la incidencia de infección tras procedimientos de derivación de líquido cefalorraquídeo

Infection is a major complication after cerebrospinal fluid (CSF) shunt systems insertion. Antibiotic-impregnated (AI) catheters seem to reduce infection rate in clinical practice. The objective of this study was to determine if the use of AI catheters reduces Staphylococcus spp. infection rate, as it is the most commonly isolated organism. Authors retrospectively reviewed all patients who underwent rifampin-impregnated and clindamycin-impregnated catheters at our hospital. These included external ventricular catheters (inserted from January 2006 to January 2007) and internalized shunts (inserted from January 2004 to January 2007). They also reviewed patients who underwent insertion of non-impregnated external catheters and internalized shunts during the same periods. Overall infection rate, Staphylococcus spp. infection rate and gram negative bacilli infection rate were compared in both groups by means of chi2 test. Sixty-five procedures with AI catheters and 66 procedures with non-AI catheters were performed. Overall infection rate as well as Staphylococcus spp. infection rate were significantly lower in the AI catheters cohort (p = 0.046 and p = 0.029, respectively), without increasing gram negative bacilli infections. The use of rifampin and clindamycin-impregnated catheters is a useful tool to reduce Staphylococcus spp. infections after CSF shunting procedures. However, future clinical trials are required to confirm these results.

Prolonged exposure to antibiotic-impregnated shunt catheters does not increase incidence of late shunt infections

Antibiotic-impregnated shunt (AIS) systems have been designed to prevent the colonization of shunt components by skin flora that occurs at surgery. Although such systems may decrease the incidence of early shunt infections (those occurring within 6 months of shunt placement), it is unclear if such exposure to prolonged antibiotics leads to an increased incidence or virulence of late shunt infections (those occurring later than 6 months after shunt placement). In this study, the authors evaluate the incidence of late shunt infection after the introduction of an AIS system in a pediatric hydrocephalus population. We prospectively reviewed all pediatric patients undergoing antibiotic-impregnated CSF shunt insertion or shunt revision operations at our institution for the 33 month period between October 1, 2002 and June 31, 2005. All shunt-related complications, including shunt infection, were evaluated in those patients with later than 6 months of follow-up. A total of 153 pediatric patients (between 1 and 21 years of age) underwent 262 shunting procedures involving the use of antibiotic-impregnated catheters. All patients were followed-up for later than 6 months with a mean follow-up of 21.7 months (range 13-46 months). Ten patients (3.82%) experienced an early shunt infection within the 6-month follow-up period. No patients experienced a late shunt infection. Although concern exists that AIS systems may delay shunt infections or even increase the rate or virulence of such infections, introduction of such catheters into a pediatric hydrocephalus cohort does not significantly increase incidence of late CSF shunt infection compared to historic controls.

Antibiotic Prophylaxis for Surgical Introduction of Intracranial Ventricular Shunts

Background Systemic antibiotics and antibiotic-impregnated shunt systems are often used to prevent shunt infection. Objectives To evaluate the effectiveness of either prophylactic systemic antibiotics or antibiotic-impregnated shunt systems for preventing infection in patients who underwent surgical introduction of intracranial ventricular shunts. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and the meeting proceedings from the American Association of Neurological Surgeons and from the European Association of Neurosurgical Societies, until June 2005. Selection criteria We included randomized or quasi-randomized controlled trials comparing the use of prophylactic antibiotics (either systemic or antibiotic-impregnated shunt systems) in intracranial ventricular shunt procedures with placebo or no antibiotics. Data collection and analysis Two authors appraised quality and extracted data independently. Main results We included seventeen trials with overall 2134 participants. We performed two separate meta-analyses: one that evaluated the use of systemic prophylactic antibiotics and another that evaluated the use of antibiotic-impregnated systems. All studies included shunt infection in their primary outcome. We could not analyse all-cause mortality regarding systemic antibiotics due to lack of data. No significant differences were found (odds ratio (OR): 1.47, 95% confidence intervals (CI) 0.83 to 2.62) for this outcome regarding the use of antibiotic-impregnated catheters compared with standard ones. The use of systemic antibiotic prophylaxis and the use of antibiotic-impregnated catheters were associated with a decrease in shunt infection (OR: 0.52, 95% CI 0.36 to 0.74 and OR: 0.21, 95% CI 0.08 to 0.55 respectively). We found no significant benefit for shunt revision in both meta-analyses that evaluated systemic antibiotics and impregnated-shunt systems. We found no significant differences between the subgroups evaluated: type of shunt (internal/external, ventriculoperitoneal/ventriculoatrial), age and duration of the administration of antibiotics. Authors' conclusions We could demonstrate a benefit of systemic prophylactic antibiotics for the first 24 hours postoperatively to prevent shunt infection, regardless of the patient's age and the type of internal shunt used. The benefit of its use after this period remains uncertain. However this data derives from the rate of shunt infection, which is an intermediary outcome. Future trials should evaluate the effectiveness of different regimens of systemic antibiotics rather than placebo, and should include all-cause mortality, shunt revision and adverse events as additional outcomes. Evidence suggests that antibiotic-impregnated catheters reduce the incidence of shunt infection although more well-designed clinical trials testing the effect of antibiotic-impregnated shunts are required to confirm their net benefit.

Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts

Systemic antibiotics and antibiotic-impregnated shunt systems are often used to prevent shunt infection. To evaluate the effectiveness of either prophylactic systemic antibiotics or antibiotic-impregnated shunt systems for preventing infection in patients who underwent surgical introduction of intracranial ventricular shunts. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and the meeting proceedings from the American Association of Neurological Surgeons and from the European Association of Neurosurgical Societies, until June 2005. We included randomized or quasi-randomized controlled trials comparing the use of prophylactic antibiotics (either systemic or antibiotic-impregnated shunt systems) in intracranial ventricular shunt procedures with placebo or no antibiotics. Two authors appraised quality and extracted data independently. We included seventeen trials with overall 2134 participants. We performed two separate meta-analyses: one that evaluated the use of systemic prophylactic antibiotics and another that evaluated the use of antibiotic-impregnated systems. All studies included shunt infection in their primary outcome. We could not analyse all-cause mortality regarding systemic antibiotics due to lack of data. No significant differences were found (odds ratio (OR): 1.47, 95% confidence intervals (CI) 0.83 to 2.62) for this outcome regarding the use of antibiotic-impregnated catheters compared with standard ones. The use of systemic antibiotic prophylaxis and the use of antibiotic-impregnated catheters were associated with a decrease in shunt infection (OR: 0.52, 95% CI 0.36 to 0.74 and OR: 0.21, 95% CI 0.08 to 0.55 respectively). We found no significant benefit for shunt revision in both meta-analyses that evaluated systemic antibiotics and impregnated-shunt systems. We found no significant differences between the subgroups evaluated: type of shunt (internal/external, ventriculoperitoneal/ventriculoatrial), age and duration of the administration of antibiotics. We could demonstrate a benefit of systemic prophylactic antibiotics for the first 24 hours postoperatively to prevent shunt infection, regardless of the patient's age and the type of internal shunt used. The benefit of its use after this period remains uncertain. However this data derives from the rate of shunt infection, which is an intermediary outcome. Future trials should evaluate the effectiveness of different regimens of systemic antibiotics rather than placebo, and should include all-cause mortality, shunt revision and adverse events as additional outcomes. Evidence suggests that antibiotic-impregnated catheters reduce the incidence of shunt infection although more well-designed clinical trials testing the effect of antibiotic-impregnated shunts are required to confirm their net benefit.

Catheter-Related Bloodstream Infections in the Intensive Care Unit Population

Catheter-related bloodstream infections (CRBIs) are a cause of significant morbidity and mortality in intensive care unit patients. Development of CRBIs may occur by several mechanisms. The role of fibrin and biofilm development and their impact on therapy are described. Multiple preventative strategies related to the insertion and maintenance of the catheter site have been identified. Topical antisepsis and use of antibiotic-impregnated catheters are also beneficial for reducing the incidence of CRBI. Antibiotic lock solutionsmay be effective in preventing CRBI for select patients with longterm catheter use. Treatment of CRBIs should be based on suspected organisms, whichmost commonly include staphylococci, gram-negatives, including Pseudomonas aeruginosa andCandida species. Duration of treatment and decisions regarding catheter removal are controversial. Evaluation and treatment of potential complications of CRBIs, including endocarditis, infected thrombophlebitis, osteomyelitis, and endophthalmitis, are essential.