VP Shunt Infections Research Articles

Percutaneous cecostomy: 25-year two institution experience.

Reports of technical success, adverse events, and long-term outcome of percutaneous cecostomy in children are limited. To characterize technical success, 30-day severe adverse events, and long-term outcome of percutaneous cecostomy at two centers. A retrospective review of hospital course and long-term follow-up (through May 2022) of percutaneous cecostomy tubes placed May 1997 to August 2011 at two children's hospitals was used. Outcomes assessed included technical success (defined as successful tube placement into the colon allowing antegrade colonic enemas), length of stay, 30-day severe adverse events, surgery consults, surgical repair, VP shunt infection, ongoing flushes, tube removal, duration between maintenance tube exchanges, and deaths. A total of 215 procedures were performed in 208 patients (90 institution A, 125 institution B). Tubes were placed for neurogenic bowel (72.1%, n = 155) and functional constipation (27.9%, n = 60). Technical success was 98.1% (211/215) and did not differ between centers (p = 0.74). Surgical repair was required for bowel leakage in 5.1% (11/215) and VP shunt infection was managed in 2.1% (2/95). Compared to functional constipation, patients with neurogenic bowel had higher % tube remaining (65.3% [96/147] versus 25.9% [15/58], p < 0.001) and higher ongoing flushes at follow-up (42.2% [62/147] versus 12.1% [7/58], p < 0.001). Tube removal for dissatisfaction occurred in 15.6% [32/205] and did not differ between groups (p = 0.98). Eight deaths due to co-morbidity occurred after a median of 7.4 years (IQR 9.3) of tube access. Percutaneous cecostomy is technically successful in the vast majority of patients and provided durable access in most. Bowel leakage and VP shunt infection are uncommon, severe adverse events.

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.

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.

Ileal Ureter Utilization in Patients With Previous Urinary Diversions

To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions. A retrospective review of patients(18 years) undergoing IU creation from 1989 to 2021 was performed. 160 patients were identified. 19(12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications. Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs(4), neobladders(5), ileal conduits(7), and bladder augmentations with Monti channels(3). Fifteen had unilateral surgery and four had bilateral "reverse-7"ileal ureter creation. Average length of stay was 7.6 days (SD 2.9). Average follow up was 32.9 months(SD 27). Mean pre-operative creatinine was 1.5(SD 0.4); mean post-operative creatinine at most recent follow up was 1.6(SD 0.7). There was no significant difference between pre- and post-operative creatinine(p=0.18). One patient had a VP Shunt infection resulting VP shunt externalization, 1 had clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak and 1 wound infection. None required renal replacement therapy. Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

Characteristics of Patients with VP Shunt Malfunction in Dr. Mohammad Hoesin General Hospital between May 2018 and July 2019

Introduction: Hydrocephalus may occur when the production of cerebrospinal fluid (CSF) is excessive or, the most common cause when, the absorption of CSF is decreased. The VP Shunt is most commonly performed worldwide as the primary treatment for hydrocephalus. The complications of VP Shunt are shunt infection, mechanical malfunction and over or under-drainage. This study aims to see the characteristics of patients affected by post VP shunt infection who are treated at dr. Mohammad Hoesin Palembang&#x0D; Methods: This research was a cross-sectional descriptive study. Using secondary data from the medical records of Mohammad Hoesin Hospital, Palembang. Performed in the from May 2018 to July 2019. Samples were all patients diagnosed with malfunction and infection with VP Shunt.&#x0D; Results: There were 23 subjects participated who met study critera. VP shunt infections were mostly male (82.6%). The largest age distribution is less than 1 year old (39.1%). The most incidence occured at the age of 1-6 months (60.9%). The most common type of surgery was emergency surgery (60.8%). The most common malfunctions were caused by shunt malfunctions (69.6%).&#x0D; Conclusion: Male patients, patients age &lt;1 year old with onset of 1-6 months, and shunt malfunctons were the most common characteristic of patients diagnosed with malfunction and infection with VP Shunt.

A Retrospective Study on the Avoidability of Ventriculoperitoneal Shunt Infections in a University Hospital in Al-Khobar, Saudi Arabia.

Ventriculoperitoneal shunt infection is a major complication and the main cause of shunt failure, contributing to a high rate of morbidity and mortality among patients requiring prolonged hospitalization. Shunt infection-related complications are considered a global burden of hydrocephalus worldwide. In our hospital, King Fahad Hospital of the University, the rate of infections in similar cases reached 8% during the period from 1999 to 2001; an increase in this rate was observed in the past two years.This study analyzed the infections that occur after ventriculoperitoneal shunt placement in patients with hydrocephalus and related conditions during the period from January 2012 to April 2017. The objectives of this study were to analyze the rate of cerebrospinal fluid infections in different age groups at the King Fahd Hospital of the University and to identify the causative pathogens and methods of reducing the rate and consequences of such infections. In this retrospective study, the electronic medical records of 266 patients were reviewed and those of 131 patients were included and analyzed. We found that the prevalence rate of shunt-related infections was 24.4%, which indicates the importance of this problem. Staphylococcus epidermidis is the most commonly implicated microorganism. The most affected age groups were those of preschool children and infants. Individuals who were older than 74 years were the least affected. It was found that delayed infections were the most common type of VP shunt infection among the study population and there was no difference in the most common organisms between early, delayed, and late infections. The mean duration of antibiotic treatment used was 19.76 days. In conclusion, postoperative infections are significantly common in patients who undergo shunt-related surgeries.

Sonication Improves Pathogen Detection in Ventriculoperitoneal Shunt-Associated Infections.

Antimicrobial treatment of ventriculoperitoneal (VP) shunt infections is challenging when the causative pathogen is unknown. To evaluate the value of sonication of explanted shunt-devices to improve the microbiological detection rate. All consecutive patients undergoing revision surgery due to suspected VP-shunt infection from January 2015 to February 2017 were evaluated. Intraoperative tissue samples, wound swabs, and cerebrospinal fluid (CSF) were collected for microbiological examination. In a subgroup of patients, the removed implants were additionally sent for sonication. A total of 35 patients were included with a mean age of 57.5±18 yr, 21 were female (60%). In 13 patient's tissue samples, CSF and wound swabs were analyzed. In 22 patients, the explanted device was additionally sent for sonication. All 22 sonication cultures showed a positive microbiological result (100%), whereas with conventional microbiological methods, the causative microorganism was identified in 8 of 13 (61%; P=.018). Analyzed by method, all 22 sonication cultures (100%) were positive and 21 of 35 conventional microbiological analysis results (60%) detected the causative agent (P<.001.) In 18 patients (51%), antimicrobial treatment was started preoperatively. In those patients, the pathogen was detected in all 12 sonication cultures (100%), whereas conventional methods grew a pathogen in 3 of 6 patients (P=.005). Sonication significantly increases the microbiological yield in VP-shunt infections, especially in patients receiving antibiotics prior to diagnostics and in infections caused by low-virulent organisms. The implementation of sonication into the clinical routine can substantially increase the rate of pathogen detection allowing targeted treatment.

P.075 Rates of infection following craniotomy or craniectomy with subsequent cranioplasty in traumatic brain injury

Background: Postoperative infection is a significant cause of morbidity and mortality in traumatic brain injury (TBI) patients who undergo craniotomy and/or craniectomy. Data on the rates of infections associated with these procedures are limited. We present a single-center retrospective study on the rates of infection in post-traumatic craniotomies, craniectomies and cranioplasties. Methods: Data on 100 TBI adult patients who underwent a craniotomy, craniectomy and/or cranioplasty from 2011-2015 will be analyzed. Demographic and perioperative data including open/closed TBI, peri/postoperative infections, duration of procedure, type and mode of bone flap preservation will be retrieved. Results: Following our data collection (to be completed by the end of February), we expect infection rates of 3-20% in our study. Upon instituting a protocol similar to the Hydrocephalus Clinical Research Network’s (HCRN) ventriculoperitoneal shunt (VP) protocol, we hope to reduce our post-TBI craniotomy/craniectomy/cranioplasty infections rates to less than 10%. Our projection is based on the HCRN protocol’s 3.15% absolute risk reduction of VP shunt infections. Conclusions: The results of this study will emphasize the need for instituting robust perioperative protocols to reduce infections. Further research will be pursued following this study to establish a protocol similar to the VP shunt protocol from the HCRN, in an attempt to reduce perioperative rates of infection.

VP-shunt dysfunction caused by malaria CNS infection

Malaria is a widespread mosquito-borne infectious disease with over 300 million cases and roughly 900 thousand deaths in 2013. Cerebral involvement of malaria causes 50 % of all infection-associated deaths, especially in children below the age of 5 years. Hydrocephalus is a medical condition with abnormal accumulation of cerebrospinal fluid in physiological cavities and ventricles. Standard treatment is the implantation of a cerebrospinal fluid shunt device. A common problem associated with shunt treatment especially in pediatric patients is infection and consecutive shunt dysfunction caused by bacteriae or high protein levels clogging the valve. In these cases, Staphylococcus aureus and Staphylococcus epidermidis are predominantly found in CSF cultures. We present a case of a 2-year old boy from Saudi Arabia with a ventriculoperitoneal (VP)-shunt-dependent congenital hydrocephalus who suffered from cerebral malaria and developed consecutive shunt failure. To the best of our knowledge, shunt failure caused by malaria CNS infection with Plasmodium falciparum has not yet been reported in the literature and should be considered as a rare cause of VP-shunt failure in patients with atypical VP-shunt infections living in or traveling from endemic areas.

Bacterial and fungal meningitis in patients with cancer

To analyze cases of bacterial and fungal meningitis in patients with cancer. Retrospective chart review from 1993 to 2004 was performed of patients with cancer at our institution who had positive CSF bacterial or fungal culture. We identified 312 positive CSF cultures representing 175 unique presentations. Ninety-six cultures were deemed contaminants, leaving 79 cultures for analysis in 77 patients; 78% had prior neurosurgery. Organisms included 68% gram-positive cocci, 10% gram-positive bacilli, 14% gram-negative bacilli, 7% Cryptococcus, and 1% C. albicans. None had N. meningitidis or H. influenza. Two patients each had S. pneumoniae or L. monocytogenes. Five percent of presentations demonstrated the triad of fever, nuchal rigidity, and mental status changes. Seventy-five percent of presentations demonstrated CSF pleocytosis (> or = 10). Median CSF WBC count was 74 cells/mm(3). CSF protein was elevated and glucose was depressed in 71%. In neutropenic patients (n = 6), 4 had 0 to 1 CSF WBC/mm(3), and 2 had normal CSF. VP shunt infections were more likely to present with mental status changes. Thirty day mortality was 13%. Patients with cancer do not manifest symptoms of meningitis as often as patients without cancer and display a very different set of CSF organisms compared to a general population. The CSF inflammatory response is muted in patients with cancer with meningitis. Most patients with cancer with meningitis have had prior neurosurgery. Additionally, the organisms causing meningitis in the cancer population have shifted over time, with a decline in the organisms which typically infect immunocompromised hosts and an increase in gram-positive infections.

Identification of &lt;italic&gt;Kocuria rosea&lt;/italic&gt; by Vitek 2 GP Card

The newly designed Vitek 2 gram-positive identification card (bio Merieux, Marcy I'Etolie, France) covers 115 taxa by the broadened database. Identification of Kocuria spp is one of them. Use of this card in the routine microbiology laboratory can lead to a better understanding of the potential pathogenicity of this species Kocuria spp belongs to the family Micrococcaceae and are considered harmless saprophytes of skin and mucous membrane.1 It was previously classified into the genus Micrococcus. Stackebrndt and colleagues made a taxonomic revision of the genus Micrococcus and some strains were reclassified in the new genus Kocuria. 1Infections due to Kocuria spp are exceedingly rare. However, there have been a number of recent reports describing the association of Kocuria spp with various infections, especially in invasive infections associated with medical implant devices. Two species, Kocuria rosea and Kocuria kristinae have been reported to cause catheter-related bacteremia.2,3 Edmond et al reported the first case of Kocuria kristinae infection associated with acute cholecystitis.5 Recently, we encountered an isolate that was identified as Kocuria rosea by the Vitek 2 GP card. A 9-year-old boy presented to the Neurosurgery department with on and off vomiting since 2 months. He had no history of headache, vision loss and imbalance while walking. On examination, he had bilateral papilloedema. Cerebellar signs were absent. Magnetic Resonance Imaging (MRI) showed vermian mass measuring 4.4 ? 4.3 cm occupying the fourth ventricle and causing hydrocephalus. The child underwent ventriculoperitoneal shunt (VP Shunt) insertion under prophylactic intravenous cefoperazone-sulbactam and netilmicin, according to the departmental protocol. The child was subsequently operated for the vermian mass, the frozen section of which showed a round cell tumor, possibly medulloblastoma. 48 hours after the second surgery the child developed post-operative fever. There was no sign of infection along the shunt tract and there were no signs and symptoms suggestive of meningitis or peritonitis. CSF was obtained from the shunt reservoir under aseptic technique and was also clear and revealed no pleocytosis and no fall in glucose levels. CSF was cultured in a BacT/Alert FA/FAN bottle (bioMe rieux Hazelwood, MO, France) and yielded a growth after 2 days of incubation. It was sub cultured on blood and mac-conkey agar. After ovenight aerobic incubation at 37° c a pure growth of pale cream nonhemolytic colonies on was obtained on blood agar. It was identified as Kocuria rosea by the Vitek 2 GP card. The isolate was also identified by conventional tests. Manual tests revealed the following results: gram-positive cocci arranged in tetrads on Gram staining, facultative anaerobe, non-motile, catalase positive, coagulse negative, bacitracin sensitivity at 0.04 IU, negative nitrate reduction and positive esculin hydrolysis. Antibiotic sensitivity test was performed according to the Clinical and Laboratory Standards Institute (formerly NCCLS) guidelines for Staphylococcus aureus. The isolate was sensitive to penicillin, oxacillin, erythromycin, clindamycin, trimethoprim/sulfmethoxzole, ciprofloxcin, levofloxacin vancomycin, teichoplanin and linezolide. There was no database for MIC calculation for Kocuria spp in the Vitek system. Repeat CSF culture yielded Kocuria rosea with same antibiogram profile. Blood and urine cultures were sterile. The child was started on antibiotics and became afebrile within 24 hours and could be discharged from hospital after a one week. According to a study by Szczerba et al most strains of Kocuria are sensitive to doxycycline, ceftriaxone, cefuroxime, amikacin, and amoxicillin with clavulanic acid, but are usually resistant to ampicillin and erythromycin.5 The duration of therapy depends on the site and severity of infection. Duration of 10-14 days is recommended if bacteremia is present. In this case, the isolate probably reflected shunt tube colonization since the child had no signs Identification of Kocuria rosea by Vitek 2 GP Card 2 of 3 and symptom of VP Shunt infection and made an uneventful recovery without shunt removal within a week. The identification of Micrococci isolated from different clinical specimens is often cumbersome for the laboratory. A new Vitek 2 Gram-positive identification card GP and database were recently introduced by bioMe rieux, which allows for the identification of additional taxa including Kocuria spp 6. The 64 wellplasticIDGP card containing 43 tests covers 115 taxa and has been evaluated to perform well for the identification of medically relevant Grampositive cocci in routine clinical laboratory.7 We believe that a reliable identification of Kocuria rosea is possible with the use of the Vitek 2 GP card. Since these isolates are rare in the routine microbiology laboratory, a better understanding of the potential pathogenicity of this species will be more apparent after the report of more cases.

Placement of baclofen pumps through the foramen magnum and upper cervical spine

The baclofen pump has been utilized in children with refractory spasticity. However, in children with prior lumbar fusion, the implantation of such a device is difficult and fraught with complications. As an alternative to placing the pump catheter through the lumbar spine, we report our experience with placement of the catheter in the spinal canal via a cervical approach through the foramen magnum. We have followed three patients with prior lumbar fusion and refractory spasticity, each of whom has undergone placement of the intrathecal component of a baclofen pump via the foramen magnum. Appropriate positioning of the catheter tip at the T6 spinal level was determined using intraoperative fluoroscopy. The catheter was then tunneled to the pump in the abdominal wall. All patients experienced a significant decrease in the severity of spasticity with pump placement. The pumps continued to function properly over a follow-up period of 24, 24, and 44 months respectively. In one patient, the catheter recoiled into the subcutaneous tissues several months after its placement, thus necessitating repositioning. One of the pumps was removed 2 years later secondary to a VP shunt infection. However, there were no immediate complications related to placement of the spinal catheter. Placement of the intraspinal component of a baclofen pump via the foramen magnum is a viable alternative for patients with spastic quadriparesis with prior lumbar fusion. The tip of the spinal catheter can be positioned in the thoracic region in a similar manner to the placement traditional lumbar pumps. In our series, there were no adverse sequelae related to the surgery or catheter positioning.

VP shunt infections – does antisepsis continue to work?

VP shunt infections – does antisepsis continue to work?

The Use of Clinical Practice Guidelines (CPGs) to Evaluate Practice and Control Costs in Ventriculoperitoneal Shunt Management

Background As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources. Methods The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation. Results CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant. Conclusions The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.

1128 BILIRUBINEMIA: AN EARLY SIGN IN VENIRICULOPERITONEAL (VP) SHUNT INFECTION

Two very-low-birthweight infants with hyaline membrane disease sustained grade 3 intraventricular hemorrhage during first week leading later to hydrocephalus and VP shunt placement. Although bilirubinemia from red blood cell breakdown cleared by 3 weeks of age jaundice recurred in both infants prior to proven S. epidermidis (S.epi) shunt infection. Other tests to determine etiology of obstructive jaundice were negative. Bilirubinemia may be an early sign in VP shunt infection.