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J Neurol Surg A Cent Eur Neurosurg 2024; 85(01): 032-038
DOI: 10.1055/s-0042-1760227
Original Article

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

Mohammad Elbaroody
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Adham Ezz
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Amr Helmy Eldessouky
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Ahmed A. Aziz N. Hassan
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Ahmed Abbas Elsharkawy
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Khaled Bassim Ali
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
,
Ehab Ahmed El Refaee
1   Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
2   Department of Neurosurgery, Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie. Sauerbruchstraße, Greifswald, Germany
› Author Affiliations Funding None.
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Abstract

Background 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.

Methods 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.

Results 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.

Conclusion 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.

Keywords

ventriculoperitoneal - shunt infection - hydrocephalus complications


Publication History

Received: 02 March 2022

Accepted: 14 October 2022

Article published online:
24 January 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Choksey MS, Malik IA. Zero tolerance to shunt infections: can it be achieved?. J Neurol Neurosurg Psychiatry 2004; 75 (01) 87-91
    PubMedSearch in Google Scholar
  • 2 George R, Leibrock L, Epstein M. Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg 1979; 51 (06) 804-811
    CrossrefPubMedSearch in Google Scholar
  • 3 Kestle JRW, Riva-Cambrin J, Wellons III JC. et al; Hydrocephalus Clinical Research Network. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 2011; 8 (01) 22-29
    CrossrefPubMedSearch in Google Scholar
  • 4 Reddy GK, Bollam P, Caldito G. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg 2012; 78 (1–2): 155-163
    CrossrefPubMedSearch in Google Scholar
  • 5 Parker SL, Anderson WN, Lilienfeld S, Megerian JT, McGirt MJ. Cerebrospinal shunt infection in patients receiving antibiotic-impregnated versus standard shunts. J Neurosurg Pediatr 2011; 8 (03) 259-265
    CrossrefPubMedSearch in Google Scholar
  • 6 Simon TD, Butler J, Whitlock KB. et al; Hydrocephalus Clinical Research Network. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 2014; 164 (06) 1462-8.e2
    CrossrefPubMedSearch in Google Scholar
  • 7 Rehman AU, Rehman TU, Bashir HH, Gupta V. A simple method to reduce infection of ventriculoperitoneal shunts. J Neurosurg Pediatr 2010; 5 (06) 569-572
    CrossrefPubMedSearch in Google Scholar
  • 8 Theophilus SC, Adnan JS. A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection. Malays J Med Sci 2011; 18 (01) 30-37
    PubMedSearch in Google Scholar
  • 9 Mwang'ombe NJM, Omulo T. Ventriculoperitoneal shunt surgery and shunt infections in children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi. East Afr Med J 2000; 77 (07) 386-390
    PubMedSearch in Google Scholar
  • 10 Pirotte BJM, Lubansu A, Bruneau M, Loqa C, Van Cutsem N, Brotchi J. Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst 2007; 23 (11) 1251-1261
    CrossrefPubMedSearch in Google Scholar
  • 11 Warf BC, Alkire BC, Bhai S. et al. Costs and benefits of neurosurgical intervention for infant hydrocephalus in sub-Saharan Africa. J Neurosurg Pediatr 2011; 8 (05) 509-521
    CrossrefPubMedSearch in Google Scholar
  • 12 Laeke T, Tirsit A, Biluts H, Murali D, Wester K. Pediatric hydrocephalus in Ethiopia: treatment failures and infections: a hospital-based, retrospective study. World Neurosurg 2017; 100: 30-37
    CrossrefPubMedSearch in Google Scholar
  • 13 Ranjeva SL, Warf BC, Schiff SJ. Economic burden of neonatal sepsis in sub-Saharan Africa. BMJ Glob Health 2018; 3 (01) e000347
    CrossrefPubMedSearch in Google Scholar
  • 14 Kestle JRW, Holubkov R, Douglas Cochrane D. et al; Hydrocephalus Clinical Research Network. A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 2016; 17 (04) 391-396
    CrossrefPubMedSearch in Google Scholar
  • 15 Warf BC, Dagi AR, Kaaya BN, Schiff SJ. Five-year survival and outcome of treatment for postinfectious hydrocephalus in Ugandan infants. J Neurosurg Pediatr 2011; 8 (05) 502-508
    CrossrefPubMedSearch in Google Scholar
  • 16 Turgut M, Alabaz D, Erbey F. et al. Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 2005; 41 (03) 131-136
    CrossrefPubMedSearch in Google Scholar
  • 17 Choux M, Genitori L, Lang D, Lena G. Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 1992; 77 (06) 875-880
    CrossrefPubMedSearch in Google Scholar
  • 18 Ates N, Kafadar A, Aygun G, Yildirim A. Usage of a bundle application process in decreasing ventriculoperitoneal shunt infections. Turk Neurosurg 2020; 30 (04) 550-556
    PubMedSearch in Google Scholar
  • 19 Gathura E, Poenaru D, Bransford R, Albright AL. Outcomes of ventriculoperitoneal shunt insertion in Sub-Saharan Africa. J Neurosurg Pediatr 2010; 6 (04) 329-335
    CrossrefPubMedSearch in Google Scholar
  • 20 Bauman N, Poenaru D. Hydrocephalus in Africa: a surgical perspective. Ann Afr Surg 2008; 2 (June): 30-37
    PubMedSearch in Google Scholar
  • 21 Simon TD, Hall M, Riva-Cambrin J. et al; Hydrocephalus Clinical Research Network. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 2009; 4 (02) 156-165
    CrossrefPubMedSearch in Google Scholar
  • 22 Beckman JM, Amankwah EK, Tetreault LL, Tuite GF. Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure. J Neurosurg Pediatr 2015; 16 (06) 648-661
    CrossrefPubMedSearch in Google Scholar
  • 23 Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review. J Neurosurg Pediatr 2008; 1 (01) 48-56
    CrossrefPubMedSearch in Google Scholar
  • 24 Vinchon M, Dhellemmes P. Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 2006; 22 (07) 692-697
    CrossrefPubMedSearch in Google Scholar
  • 25 Thomas R, Lee S, Patole S, Rao S. Antibiotic-impregnated catheters for the prevention of CSF shunt infections: a systematic review and meta-analysis. Br J Neurosurg 2012; 26 (02) 175-184
    CrossrefPubMedSearch in Google Scholar
  • 26 Tulipan N, Cleves MA. Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 2006; 104 (1, Suppl): 5-8
    PubMedSearch in Google Scholar
  • 27 Mottolese C, Grando J, Convert J. et al. Zero rate of shunt infection in the first postoperative year in children: dream or reality?. Childs Nerv Syst 2000; 16 (04) 210-212
    CrossrefPubMedSearch in Google Scholar
  • 28 Kalangu KKN, Esene IN, Dzowa M, Musara A, Ntalaja J, Badra AK. Towards zero infection for ventriculoperitoneal shunt insertion in resource-limited settings: a multicenter prospective cohort study. Childs Nerv Syst 2020; 36 (02) 401-409
    CrossrefPubMedSearch in Google Scholar
  • 29 Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 2001; 94 (02) 195-201
    CrossrefPubMedSearch in Google Scholar
  • 30 McGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 2003; 36 (07) 858-862
    CrossrefPubMedSearch in Google Scholar
  • 31 Di Rocco C, Marchese E, Velardi F. A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991-1992 Education Committee of the ISPN. Childs Nerv Syst 1994; 10 (05) 321-327
    CrossrefPubMedSearch in Google Scholar
  • 32 Rozzelle CJ, Leonardo J, Li V. Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial. J Neurosurg Pediatr 2008; 2 (02) 111-117
    CrossrefPubMedSearch in Google Scholar
  • 33 Grice EA, Kong HH, Conlan S. et al; NISC Comparative Sequencing Program. Topographical and temporal diversity of the human skin microbiome. Science 2009; 324 (5931): 1190-1192
    CrossrefPubMedSearch in Google Scholar
  • 34 Gutierrez-Murgas Y, Snowden JN. Ventricular shunt infections: immunopathogenesis and clinical management. J Neuroimmunol 2014; 276 (1–2): 1-8
    CrossrefPubMedSearch in Google Scholar
  • 35 Darouiche RO, Wall Jr MJJ, Itani KMF. et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362 (01) 18-26
    CrossrefPubMedSearch in Google Scholar
  • 36 Gyssens IC. Preventing postoperative infections: current treatment recommendations. Drugs 1999; 57 (02) 175-185
    CrossrefPubMedSearch in Google Scholar
  • 37 Klimo Jr P, Van Poppel M, Thompson CJ, Baird LC, Duhaime AC, Flannery AM. Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis. J Neurosurg Pediatr 2014; 14 (Suppl. 01) 44-52
    CrossrefPubMedSearch in Google Scholar
  • 38 Langley JM, LeBlanc JC, Drake J, Milner R. Efficacy of antimicrobial prophylaxis in placement of cerebrospinal fluid shunts: meta-analysis. Clin Infect Dis 1993; 17 (01) 98-103
    CrossrefPubMedSearch in Google Scholar
  • 39 Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 2006; (03) CD005365
    PubMedSearch in Google Scholar
  • 40 Scottish Antimicrobial Prescribing Group (SAPG). Antiobiotic Prophylaxis in Neurosurgery. Glasgow: SAPG; 2018
    Search in Google Scholar
  • 41 Parker SL, Attenello FJ, Sciubba DM. et al. Comparison of shunt infection incidence in high-risk subgroups receiving antibiotic-impregnated versus standard shunts. Childs Nerv Syst 2009; 25 (01) 77-83 , discussion 85
    CrossrefPubMedSearch in Google Scholar
  • 42 Sciubba DM, Stuart RM, McGirt MJ. et al. Effect of antibiotic-impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J Neurosurg 2005; 103 (2, Suppl): 131-136
    PubMedSearch in Google Scholar
  • 43 Bauer DF, Baird LC, Klimo P. et al. Congress of neurological surgeons systematic review and evidence-based guidelines on the treatment of pediatric hydrocephalus: update of the 2014 guidelines. Neurosurgery 2020; 87 (06) 1071-1075
    CrossrefPubMedSearch in Google Scholar
  • 44 Tamber MS, Klimo Jr P, Mazzola CA, Flannery AM. Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: management of cerebrospinal fluid shunt infection. J Neurosurg Pediatr 2014; 14 (Suppl. 01) 60-71
    CrossrefPubMedSearch in Google Scholar
  • 45 Klimo Jr P, Thompson CJ, Ragel BT, Boop FA. Antibiotic-impregnated shunt systems versus standard shunt systems: a meta- and cost-savings analysis. J Neurosurg Pediatr 2011; 8 (06) 600-612
    CrossrefPubMedSearch in Google Scholar
  • 46 Zhou W-X, Hou W-B, Zhou C. et al. Systematic review and meta-analysis of antibiotic-impregnated shunt catheters on anti-infective effect of hydrocephalus shunt. J Korean Neurosurg Soc 2021; 64 (02) 297-308
    CrossrefPubMedSearch in Google Scholar
  • 47 Vlasak A, Okechi H, Horinek D, Albright AL. Pediatric ventriculoperitoneal shunts revision rate and costs in high-volume sub-Saharan department. World Neurosurg 2019; 130: e1000-e1003
    CrossrefPubMedSearch in Google Scholar
  • 48 Lam SK, Srinivasan VM, Luerssen TG, Pan IW. Cerebrospinal fluid shunt placement in the pediatric population: a model of hospitalization cost. Neurosurg Focus 2014; 37 (05) E5
    CrossrefPubMedSearch in Google Scholar
  • 49 Gutiérrez-González R, Boto GR, Pérez-Zamarrón A. Cerebrospinal fluid diversion devices and infection. A comprehensive review. Eur J Clin Microbiol Infect Dis 2012; 31 (06) 889-897
    CrossrefPubMedSearch in Google Scholar
  • 50 Moussa WMM, Mohamed MAA. Efficacy of postoperative antibiotic injection in and around ventriculoperitoneal shunt in reduction of shunt infection: a randomized controlled trial. Clin Neurol Neurosurg 2016; 143: 144-149
    CrossrefPubMedSearch in Google Scholar
  • 51 Rotim K, Miklic P, Paladino J, Melada A, Marcikic M, Scap M. Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 1997; 13 (11–12): 584-587
    CrossrefPubMedSearch in Google Scholar