Ventriculoperitoneal Shunt Infection Research Articles

Effect of cranial entry site on the rate of proximal catheter misplacement in ventriculoperitoneal shunt insertion.

The insertion of a ventriculoperitoneal shunt (VPS) is a common neurosurgical procedure, but the optimal entry site of the ventricular catheter is still under debate. In this study, the authors compare the parietal (Keen's) and frontal (Kocher's) entry sites in terms of the rate of revision surgery due to ventricular catheter misplacement, VPS dysfunction, and VPS infection. The authors retrospectively analyzed the data on consecutive adults (age ≥ 18 years) who had undergone primary VPS insertion between 2010 and 2020 at two neurosurgical centers. One center regularly inserts the ventricular catheter frontally (frontal group); the other center, parietally (parietal group). The primary outcome of interest was the rate of ventricular catheter misplacement necessitating revision surgery. Secondary outcomes were functional outcome as measured by the modified Rankin Scale (mRS), rate of revision surgery for VPS dysfunction and infection, as well as early (≤ 30 days) and late (> 30 days) mortality rates. Propensity score matching was performed based on baseline variables, such as normal pressure hydrocephalus, postinfectious hydrocephalus, and idiopathic intracranial hypertension, which were identified as predictors of ventricular catheter misplacement using logistic regression analysis. Among 539 consecutive patients, 301 (55.8%) were in the frontal group and 238 (44.2%) in the parietal group. Postoperative rates of revision surgery due to misplacement were comparable in the two catheter entry site groups (frontal 14 [4.7%] vs parietal 11 [4.6%], p = 0.987). Rates of revision surgery for VPS dysfunction (14 [4.7%] vs 10 [4.2%], respectively, p = 0.802) and infection (22 [7.3%] vs 10 [4.2%], p = 0.13) exhibited no significant differences. Favorable functional outcomes (mRS score ≤ 2; 164 [76.3%] vs 174 [79.5%], respectively, p = 0.058) and early mortality rates (5 [1.7%] vs 6 [2.5%], p = 0.483) were similar between the groups. After propensity score matching, the primary and secondary outcome measures remained comparable between the groups. The entry site of the ventricular catheter in VPS surgery does not seem to affect proximal revision rates. Further, revision rates due to VPS dysfunction, VPS infection, and morbidity were comparable as well.

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.

Measurement of cerebrospinal fluid lactate levels in pediatric patients with suspected ventriculoperitoneal shunt infection: A retrospective cohort study

IntroductionVentriculoperitoneal shunt (VPS) infection is a severe complication. Early diagnosis could help to decrease morbidity and treatment costs. Lactate has been used for the diagnosis of other central nervous system infections. The aim of this study is to determine the usefulness of lactate for the diagnosis of VPS infection. MethodologyRetrospective cohort study. Lactate was measured in patients who consulted with VPS dysfunction between May 2019 and May 2022. Mean were compared according to culture results. A Receiver Operating Characteristic (ROC) curve was performed to determine the appropriate cut-off point. ResultLactate has a high negative predictive value but a low positive predictive value for the diagnosis of ventriculitis.

Ventriculoperitoneal shunt infection rate and other associated complications of VP shunt insertion in Abuja, Nigeria

BackgroundComplications associated with ventriculoperitoneal shunt insertion constitute a significant cause of morbidity and mortality among hydrocephalus patients. Despite this, VP shunt placement has remained the mainstay of treatment for hydrocephalus. The aim of this study is to evaluate the complications of VP shunt surgery in our environment and to identify the risk factors associated with it. MethodologyPatients who had VP shunt surgery over a period of two years (Jan 2015–December 2016) were evaluated retrospectively by reviewing their hospital records. The patients’ demography, aetiology and clinical presentation of the hydrocephalus, and complications were analysed using SPSS version 26.0. Results were presented in tables and figures. ResultsA total of 69 patients who had VP shunt over the study period had complete medical records available for review. Their age ranged between 2days and 68years with a male to female ratio of 1.8:1. Overall complication rate was 30.4%. Shunt malfunction (11.5%) and shunt infection (7.2%) were the commonest complications recorded. Late presentation was the most important risk factor for shunt complications. ConclusionThe rate of shunt complications seen in this study compares fairly with studies in other parts of the world.

Comparative analysis of linezolid, vancomycin, and hyperbaric oxygen therapies in a rat model of ventriculoperitoneal shunt infection.

Staphylococcus epidermidis is the most common causative microorganism of ventriculoperitoneal shunt infections. This study aimed to compare linezolid and vancomycin treatments and to examine the effect of these antibiotics alone and combined with hyperbaric oxygen therapy on the amount of bacterial colonies in the experimental S. epidermidis shunt infection model. A shunt catheter was placed in the cisterna magna of 49 adult male Wistar albino rats. The rats were randomly divided into seven groups, as follows: sterile control, infected control, vancomycin, linezolid, hyperbaric oxygen, vancomycin + hyperbaric oxygen, linezolid + hyperbaric oxygen. In all groups except the sterile control group, 0.2ml 107CFU/mL S. epidermidis was inoculated to the cisterna magna. Parenteral vancomycin was administered 40mg/kg/day to the vancomycin groups, and 50mg/kg/day of enteral linezolid to the linezolid groups. Hyperbaric oxygen groups were given 100% oxygen at a pressure of 2.4 ATA for 50min a day. One day after the last treatment, colony quantities in the shunt catheters and CSF were analyzed. The number of CSF colonies in the linezolid group was significantly lower than in the vancomycin group (p < 0.05). The number of CSF colonies in the linezolid + HBO group was significantly lower than in the vancomycin + HBO group (p < 0.05). Linezolid treatment was found to be more effective than vancomycin in ventriculoperitoneal shunt infection caused by S. epidermidis. There was no statistical difference among other treatment groups. Hyperbaric oxygen therapy is shown to contribute to the sterilization of cultures.

Pediatric Fungal Ventriculoperitoneal Shunt Infection Due to Paecilomyces.

Pediatric Fungal Ventriculoperitoneal Shunt Infection Due to Paecilomyces.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population.

To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies. Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records. Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected. The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

Incidence of Ventriculoperitoneal (VP) Shunt Infection In Vancomycin-Drenched VP Shunts

Objective: To determine the occurrence of infection in patients with VP (Ventriculoperitoneal) shunts that were drenched in vancomycin. Materials and Methods: A descriptive case series study was done in The Department of Neurosurgery, Lady Reading Hospital, Peshawar, Pakistan from 10 September 2019 to 31 December 2020 to ascertain the frequency of VP shunt infections in vancomycin-drenched VP shunts. The patients were followed for 06 months. Results: A total of 100 patients were included in this study. There were 44 (44%) men and 56 (56%) women. Age ranged from birth to 18 years. Patients younger than 1 year were 44 (44%), older than 1 to 10 years were 33 (33%) and older than 10 years were 23 (23%). Congenital hydrocephalus was the most common type observed in 49 (49%) patients. Shunt infection occurred in 7 patients (7%) within 6 months after surgery. Staphylococcus aureus was the most common pathogen identified in 05 of 07 (71%) infected patients. P value &lt;0.05 was observed in Vancomycin-soaked VP shunts and shunt infection, which is significant. Conclusion: The rate of shunt infection was significantly reduced when 2 mg/mL topical vancomycin was used intraoperatively (intra- and peri-shunt) in conjunction with a multi-step shunt infection prevention program. This treatment may be less expensive than using an antibiotic-impregnated catheter (AIC).

1319. Microbiology and Epidemiology of Pediatric Ventriculoperitoneal Shunt Infections

Abstract Background Infections complicate approximately 10% of ventriculoperitoneal (VP) shunts in children, with considerable associated morbidity and mortality. Recent guidelines for empiric treatment of VP shunt infections recommend use of vancomycin combined with an anti-pseudomonal beta-lactam, but are based on low-quality evidence. We aimed to further characterize and update the microbiology of pediatric VP shunt infections using the U.S. Military Health System database. Methods Department of Defense beneficiaries less than 22 years-of-age admitted for VP shunt infection between Oct 1, 2008 and Sep 30, 2019 were included. VP shunt infection was defined using a combination of ICD-9-CM and ICD-10-CM codes, CPT codes for removal or replacement of a shunt (Table 1), and positive cultures from a normally sterile site (cerebrospinal fluid, blood, catheter tip, and peritoneum). Demographic data on age, sex, and year of admission were collected for each patient, as was microbiologic data including organism and specimen source. Results There were 32 qualifying admissions among 30 patients for VP shunt infection over the 10-year study period, with no discernable year-to-year trend identified. Half of all VP shunt infections occurred in patients less than 12 months of age (Table 2). Sixty-one unique positive cultures were identified among the 30 patients, 38 (62%) from CSF samples, and the remaining 23 (38%) from blood, peritoneum, and catheter tips (Figure 1). Coagulase-negative Staphylococcus (28%), Staphylococcus aureus (15%), and Enterococcus spp. (10%) were the leading causative pathogens (Figure 2). Enteric gram-negative rods accounted for 21% of positive cultures. Pseudomonas spp. were rarely isolated (3%), however, strict anaerobic pathogens made up 8% of positive cultures. Conclusion Empiric antibiotic treatment of VP shunt infections in children should cover gram-positive cocci and enteric gram-negative rods but need not cover Pseudomonas spp. Existing guidelines do not recommend anaerobic coverage, however, these data indicate empiric anaerobic coverage is prudent, especially when an intra-abdominal VP shunt infection is suspected. Disclosures All Authors: No reported disclosures

The Prognostic Nutritional Index and Mortality in Patients With Ventriculoperitoneal Shunt Infection

The objective of this study was to investigate the relationship between mortality and the prognostic nutritional index (PNI) in the pediatric patient group with ventriculoperitoneal shunt (VPS) infection. A total of 63 pediatric patients with a VPS infection and positive cerebrospinal fluid (CSF) culture were retrospectively registered. The CSF specimens were analyzed to conduct culture and microscopic evaluation. A total of 44.4% of the cases were men and 55.6% of the cases were women. Patients were divided into 2 groups (survivor and non-survivor patients). When survivor and non-survivor patients were compared, it was found that CSF leukocytes, CSF glucose, CSF protein, CSF/blood glucose ratio, lymphocyte, albumin, and PNI levels were lower in the non-survivor patients’ group. Nevertheless, blood glucose and CRP (C-reactive protein) were significantly higher in the non-survivor patients’ group than in the survivor patients’ group. In our investigation, we suggested that low PNI was related to high mortality in cases of VPS infection.

Propionibacterium acnes: A Difficult-to-Diagnose Ventriculoperitoneal Shunt Infection. Case Report.

Ventriculoperitoneal (VP) shunt infections are a fairly common complication in both the early and late postoperative periods. Sometimes diagnosis is difficult despite the fact that infection is often accompanied by clinical symptoms. Furthermore, pathogenic bacteria can be detected in the cerebrospinal fluid. We describe a case of chronic VP shunt infection in a 24-year-old female patient who was operated on for posterior fossa pilocytic astrocytoma and needed a VP shunt. The infection revealed itself 5 years after shunt implantation with nonspecific symptoms, and it took approximately 2 years to make a correct diagnosis. Meanwhile, the patient's condition became critical. The infection was caused by Propionibacterium acnes, which is capable of forming biofilms on implants, and which is difficult to identify due to the peculiarity of its cultivation. When the bacterium was identified, the shunt was replaced and antimicrobial therapy was performed, after which the patient's condition improved dramatically and she got back to her normal life. This case shows how difficult the diagnosis of VP shunt infection can be and what clinical significance it can have for the patient.

Relationship between catheter related cerebrospinal fluid infections and systemic immune-inflammation index.

This study investigated the relationship between the systemic immune inflammation index (SII) and catheter-related infections and their effects on prognosis in pediatric patients. A total of 56 pediatric patients diagnosed with ventriculoperitoneal (V-P) shunt infection between January 2017 and October 2019 were included. V-P shunt infection diagnosis was made based on clinical findings. All cerebrospinal fluid (CSF) samples were subjected to direct microscopic examination and culture. Protein, glucose, and sodium levels in CSF, CSF leukocytes, and hematological and biochemical parameters were measured. Fifty-six patients with growth in CSF culture were included in this study. 55.4% of the cases were female and 44.6% male. V-P shunt was detected in 82.1% of the cases and external ventricular drainage (EVD) catheter-related infection in 17.9%. The CSF/blood glucose ratio was significantly lower (p=0.046), and SII was significantly increased (p=0.002) in non-coagulase-negative staphylococci. Early and appropriate antibiotic therapy reduces morbidity and mortality in catheter-related infections. However, it is important to start empirical antibiotherapy until culture results are expected. Therefore, further research on the estimation of possible factors is needed.

Role of Bangladesh Medical College Hospital (B.M.C.H) Protocol in Achieving Zero Shunt Infection in Paediatric Hydrocephalus

Ventriculoperitoneal shunt infection is one of the most dreadful complications of shunt surgery. Though topical, intravenous, and intraventricular antibiotics have been used; the infection rate is still high. It is a retrospective cohort study from Jan 2018 to Dec 2022 in Bangladesh Medical College, performed by a single Neurosurgeon. Objective: To see the effectiveness of the B.M.C.H protocol of shunt surgery in minimizing shunt infection. Method: 83 pediatric Ventriculo Peritoneal shunt cases were selected, who met the inclusion criteria. They were divided into 2 groups. One group had an Ommaya reservoir with or without endoscopic third ventriculostomy (failed) and was subject to cerebrospinal fluid aspiration for a considerable period followed by a shunt. The other group had conventional shunt (non-Ommaya) surgery. Results: The overall infection rate in our hospital in shunt surgery is 3.6%. Among the non-Ommaya or conventional shunt group, it reached 7.1%, while among the Ommaya group, there was not a single shunt infection in the follow-up period. 47% of babies came from the poorest population of the country. There was no significant relationship found between infection with a history of previous infection, per operative use of an endoscope, early age, or preterm birth. Follow up period was between 6 to 18 months. Conclusions: In a non-specialized hospital in a third-world country with limited neurosurgical capacity, following B.M.C.H. protocol, we found the babies who had Ommaya reservoir and underwent regular cerebrospinal fluid aspiration for a period of time before Ventriculo peritoneal shunt surgery were infection free in the long and short time follow up.

Bacterial ventriculoperitoneal shunt infections: changing trends in antimicrobial susceptibility, a 7-year retrospective study from Pakistan

BackgroundVentriculoperitoneal (VP) shunt infections in adults represent a severe complication and make treatment more challenging. Therefore, drug susceptibility patterns are crucial for therapeutic decisions and infection control in neurosurgical centers. This 7-year retrospective study aimed to identify the bacteria responsible for adult VP shunt infections and determine their drug susceptibility patterns.MethodsThis single-center study was performed from 2015 to 2021 in Lahore, Pakistan, and included CSF cultures from VP shunt infections. Demographic data, causative organisms, and antimicrobial susceptibility testing results were collected. Multivariate analysis of variance (MANOVA) and two-sample t-tests were used to analyze and compare the antibiotic sensitivity trends over the study period.Results14,473 isolates recovered from 13,937 CSF samples of VP shunt infections were identified and analyzed for their susceptibility patterns to antimicrobials. The proportion of Gram-negative and Gram-positive bacteria were 11,030 (76%) and 3443 (24)%, respectively. The predominant bacteria were Acinetobacter species (n = 5898, 41%), followed by Pseudomonas species (n = 2368, 16%) and coagulase-negative Staphylococcus (CoNS) (n = 1880, 13%). 100% of Staphylococcus aureus (S.aureus) and CoNS were sensitive to vancomycin and linezolid (n = 2580). However, 52% of S. aureus (719/1,343) were methicillin-resistant Staphylococcus aureus (MRSA). Acinetobacter showed maximum sensitivity to meropenem at 69% (2759/4768). Pseudomonas was 80% (1385/1863 sensitive to piperacillin-tazobactam, Escherichia coli (E. coli) showed 72% to amikacin (748/1055), while Klebsiella spp. was 57% (574/1170) sensitive to piperacillin-tazobactam. The sensitivity of piperacillin-tazobactam and meropenem for Gram-negative bacteria decreased significantly (p < 0.05) over 7 years, with 92.2% and 88.91% sensitive in 2015 and 66.7% and 62.8% sensitive in 2021, respectively.ConclusionThe significant decrease in the effectiveness of carbapenem and beta-lactam/beta-lactamase inhibitor combination drugs for the common Gram-negative causative agents of VP shunt infections suggests that alternative antibiotics such as colistin, fosfomycin, ceftazidime/avibactam, ceftolozane/tazobactam, and tigecycline should be considered and in consequence included in testing panels. Additionally, it is recommended to adopt care bundles for the prevention of VP shunt infection.

Ventriculoatrial and ventriculoperitoneal shunt malfunction and infection in infants with necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) and posthemorrhagic hydrocephalus are both conditions that can affect preterm infants. The peritoneum is the preferred terminus for shunt placement, but another terminus is sometimes used due to subjective concerns about infection and complications related to NEC. The aim of this study was to examine the rates of ventriculoatrial (VA) and ventriculoperitoneal (VP) shunt infection and failure in pediatric patients with a history of NEC. A single-center retrospective review of medical records from 2009 to 2021 was performed to identify pediatric patients with NEC who underwent shunt placement before 2 years of age. Patients were excluded if shunt placement preceded NEC diagnosis. Patient demographic characteristics, timing of shunt placement, type of shunt, shunt infections or revisions, and timing and management of NEC were extracted. The Student t-test and Fisher exact test were used to calculate significance. Kaplan-Meier curves were calculated. Twenty-two patients met the inclusion criteria. Most patients underwent VP shunt placement (16 [71.4%]). Patients who underwent surgical management of NEC compared with those who underwent medical management were more likely to have a VA shunt placed (p = 0.02). One VA shunt and 3 VP shunts became infected during follow-up (p = 0.7). The mean time until infection was not significantly different between VA and VP shunts (p = 0.73). Significantly more VA shunts required revision (83% vs 31%, p = 0.04), and VA shunts had a significantly shorter time until failure (3.0 ± 0.8 vs 46.3 ± 7.55 months, p = 0.03). VP shunts had a significantly longer time until failure than VA shunts; these shunts had similar infection rates in infants with prior NEC. When feasible, neurosurgeons and pediatric general surgeons can consider placing a VP shunt even if the patient has a history of NEC.

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 ...

Effects of Intraventricular Vancomycin Administration on the Prevention of Ventricular Shunt Infection.

Shunt infection causes death in many patients diagnosed with hydrocephalus and increases the duration of hospitalization and treatment costs. A high percentage of children are forced to undergo re-surgery due to shunt dysfunction or infection. The present study aimed to investigate the role of intraventricular (IVT) vancomycin in the prevention of ventricular shunt infection in children with hydrocephalus who were referred to Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. The present descriptive cross-sectional study was conducted on 192 children with hydrocephalus who underwent shunt surgery at Akbar Hospital in Mashhad, Iran, between the years 2017 and 2021. Patients were divided into two groups of intervention (n=69) and control (n=123). The patients in the intervention group received 30 mg of IVT vancomycin during shunt surgery. The rate of shunt obstruction and infection were then compared between the two study groups. The two study groups were matched in terms of demographic and clinical information except for gender (P=0.02). Moreover, no significant difference was reported between the two groups in terms of intelligence development (χ2=0.51; P=0.47), verbal development (χ2=0.1; P=0.75), and movement development (χ2=1.05; P=0.3). The frequency of shunt infection and shunt obstruction was estimated at 8.8% and 18.2%, respectively. The shunt infection rate was lower in the vancomycin IVT group than in the control group (χ2=4.07; P=0.04), while no difference was observed between the two groups in terms of shunt obstruction (χ2=3.66; P=0.056). The comparison of the two study groups indicated no significant difference between them in terms of mortality (χ2=0.004; P=0.95). It seems that IVT vancomycin should be recommended for inclusion in hydrocephalus surgery protocol to reduce postoperative shunt infection. It is recommended that shunt protocols be adopted in future multicenter prospective randomized controlled trials on the reduction of ventriculoperitoneal shunt infections to further evaluate the efficacy of IVT antibiotics.

The First Report of Chryseobacterium gleum Caused Ventriculoperitoneal-shunt Infection in a Child.

To The Editors: Ventriculoperitoneal (VP) shunt is one of the most widely used and effective methods in the treatment of hydrocephalus in childhood. VP shunt infections have been observed in approximately 3.2%–25%, and Chryseobacterium spp. is a rare cause of VP shunt infections.1,2 Herein, we report the first VP shunt infection caused by Chryseobacterium gleum. A 12-month-old female (corrected age 8 months) born via spontaneous vaginal delivery, weighed 700 g at 25 weeks of gestation, was admitted to our emergency department with a fever with a maximum peak temperature of 39°C, projectile vomiting, and decreased oral intake. Her history included long-term ventilation in the neonatal intensive care unit with a diagnosis of moderate bronchopulmonary dysplasia. At 4 months of age, she developed intraventricular hemorrhage and progressive hydrocephalus, and a VP shunt was inserted. She had several episodes of VP shunt infections caused by S. epidermidis and S. aureus. At admission, the patient was febrile, tachycardic (heart rate, 160/min) and tachypneic (respiratory rate of 48/min). Physical examination showed weakness, lethargy and sleepiness. Her total Glasgow Coma Scale score was 12 (E3V4M5). Laboratory tests were as follows: white blood cell (WBC) count: 12.5 × 103/μL (neutrophil 37% and lymphocyte 54%), C-reactive protein: 20 mg/L, procalcitonin: 0.09 μg/L. The cerebrospinal fluid (CSF) WBC count was 120/mm3, protein 107 mg/dL and glucose 42 mg/dL. With the preliminary diagnoses of sepsis and shunt infection, intravenous (IV) cefotaxime (300 mg/kg/day) and IV vancomycin (60 mg/kg/day) was initiated empirically. Peripheral/catheter blood cultures and CSF samples were inoculated into aerobic and anaerobic culture bottles (BacT/ALERT, BioMérieux, Durham, USA). The patient underwent VP shunt externalization. The blood and urine cultures were negative during the patient’s follow-up. Chryseobacterium gleum was isolated in the CSF, shunt and ventricular catheter tip cultures on the 3rd day of treatment. The organism had high-level minimum inhibitory concentration (MIC) levels for meropenem (MIC = 32 μg/mL), imipenem (MIC = 32 μg/mL) and piperacillin-tazobactam (MIC = 250 μg/mL). MIC level of ciprofloxacin was 0.125 μg/mL and trimethoprim-sulfamethoxazole was 0.5 μg/mL. Cefotaxime and vancomycin were switched to IV trimethoprim/sulphamethoxazole (5 mg/kg every 6 hours) and ciprofloxacin (10 mg/kg every 8 hours). On the 5th day of the combined therapy, the patient’s CSF sample was evaluated and showed a WBC count of 30/mm3, glucose 42 mg/dL and protein 360 mg/ dL, and the CSF culture was sterile. Antibiotics were continued for 21 days. The patient was clinically stable, and no adverse effects or seizures were observed during or after the treatment. The extra ventricular drainage was removed, the VP shunt was inserted following 2 consecutive negative CSF cultures, and the patient was discharged. Chryseobacterium species are common in nature but are not found in human flora. Most cases are nosocomial and are frequently associated with immunosuppression or implantable devices. Chryseobacterum gleum is typically a low-virulence organism that can cause serious infections. It has been reported that Chryseobacterum gleum can cause infections such as central-line-associated bloodstream infection, community-acquired pneumonia and urinary tract infection in adults.3–5 Unlike previous reports, Chryseobacterium was isolated in the cerebrospinal fluid in our study. Chryseobacterum gleum commonly colonizes mechanical devices, causing device-associated infections, and can form biofilm. According to this study, VP shunt may be a risk factor for Chryseobacterium gleum infections. This report emphasizes the significance of Chryseobacterium species as a causative agent of a wide range of infections, and VP shunts can pose a risk for this agent. Data on the management of Chryseobacterium is limited. Antimicrobial susceptibility testing guidelines for Chryseobacterium infections should be developed for more effective and accurate treatment.

Correlation between cerebrospinal fluid abnormalities before ventriculoperitoneal shunt and postoperative intracranial infection in adult patients with hydrocephalus: A clinical study.

To identify the relationship between preoperative cerebrospinal fluid (CSF) leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels and ventriculoperitoneal shunt infection. Records of 671 consecutive adult patients who underwent ventriculoperitoneal shunt surgery for the treatment of hydrocephalus at Zhujiang Hospital affiliated with Southern Medical University from January 2011 to March 2022 were reviewed. The patients were divided into infection and non-infection groups based on the presence of postoperative infection. For all patients, we analyzed age; sex; primary disease; preoperative CSF leukocyte, chloride, glucose, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase, lactic acid and protein levels; postoperative temperature; and postoperative infection. A total of 397 patients were included, 28 (7.05%) of whom had an infection within 6 months of the operation and the remaining had no infection. There was no significant difference in age, sex, primary disease, leukocyte, chloride ion, aspartate aminotransferase, lactate dehydrogenase, adenosine deaminase and protein levels in CSF between infection group and non-infection group (p > 0.05). The postoperative infection rate of patients with CSF glucose < 2.8 mmol/L (x 2 = 11.650, p = 0.001) and CSF lactic acid >2.8 mmol/L (x 2 = 12.455, p < 0.001) was higher than that of patients with CSF glucose level ≥2.8 mmol/L and CSF lactic acid level in the range of (1-2.8) mmol/L, respectively, with statistical difference. Compared with the non-infection group, the level of CSF glucose (t = 4.113, p < 0.001) was significantly lower, and the level of CSF lactic acid (t = 6.651, p < 0.001) was significantly higher in the infection group. Multivariate logistic regression analysis showed that preoperative cerebrospinal fluid glucose < 2.8 mmol/L (OR = 3.911, 95% CI: 1.653~9.253, p = 0.002) and cerebrospinal fluid lactate >2.8 mmol/L (OR = 4.712, 95% CI: 1.892~11.734, p = 0.001) are risk factors for infection after ventriculoperitoneal shunt. ROC analysis revealed that the area under the curve (AUC) for CSF glucose and lactic acid level were 0.602 (95% CI: 0.492-0.713) and 0.818 (95% CI: 0.738-0.898), respectively. The infection group had higher rates of fever and body temperature on postoperative day 3-7 (p < 0.05). For adult hydrocephalus patients without clinical manifestations of intracranial infection but only with simple abnormality of cerebrospinal fluid, when the content of glucose in cerebrospinal fluid is < 2.8 mmol/L, and the content of lactic acid is >2.8 mmol/L, it is recommended to perform ventriculoperitoneal shunt after further improvement of cerebrospinal fluid indicators, otherwise, hasty operation will increase the postoperative infection rate. The postoperative fever rate of ventriculoperitoneal shunt surgery is high and the body temperature drops rapidly. If there is still fever after day 3 after surgery, whether there is intracranial infection should be considered.

Is It Possible to Eliminate Postoperative Shunt Infections?: Results of a Modified Hydrocephalus Clinical Research Network Protocol.

Postoperative shunt infection is a nightmare in neurosurgical practice with additional morbidity and mortality. A lot of protocols have contributed to the reduction of ventriculoperitoneal shunt (VPS) infections but not eradication. The aim of the study was to evaluate the rigid application of a modified Hydrocephalus Clinical Research Network (HCRN) protocol in the prevention of postoperative shunt infection. We retrospectively evaluated children with congenital hydrocephalus who underwent VPS insertion, and in whom the protocol was applied from June 2019 to January 2020. Follow-up ranged from 11 to 24 months. Thirty-seven procedures were performed including 35 primary shunt insertions and two revision surgeries. The median age was 5 months (range, 1-30 months), and 25 patients were males. The most common cause for VPS placement was congenital hydrocephalus without identifiable cause in 28 cases (80%). The endoscope-assisted technique was used in the insertion of the proximal end in six cases (17%). The mean follow-up was 19.4 months (11-24 months). The rate of shunt infection was 0% till the last follow-up. The preliminary results showed an effective method for the prevention of postoperative shunt infections using the modified protocol. These initial findings need to be validated in a large prospective study before widespread application can be recommended.