1
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Skar G, Flannigan L, Latch R, Snowden J. Meningitis in Children: Still a Can't-Miss Diagnosis. Pediatr Rev 2024; 45:305-315. [PMID: 38821894 DOI: 10.1542/pir.2023-006013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 06/02/2024]
Abstract
Although vaccination and antimicrobial treatment have significantly impacted the frequency and outcomes of meningitis in children, meningitis remains a critical can't-miss diagnosis for children, where early recognition and appropriate treatment can improve survival and neurologic outcomes. Signs and symptoms may be nonspecific, particularly in infants, and require a high index of suspicion to recognize potential meningitis and obtain the cerebrospinal fluid studies necessary for diagnosis. Understanding the pathogens associated with each age group and specific risk factors informs optimal empirical antimicrobial therapy. Early treatment and developmental support can significantly improve the survival rates and lifelong neurodevelopment of children with central nervous system infections.
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Affiliation(s)
- Gwenn Skar
- University of Nebraska Medical Center, Omaha, NE
| | | | - Rebecca Latch
- Department of Pediatrics
- Arkansas Children's, Little Rock, AR
| | - Jessica Snowden
- Department of Pediatrics
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
- Arkansas Children's, Little Rock, AR
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2
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Adapa AR, Linzey JR, Moriguchi F, Daou BJ, Khalsa SSS, Ponnaluri-Wears S, Thompson BG, Park P, Pandey AS. Risk factors and morbidity associated with surgical site infection subtypes following adult neurosurgical procedures. Br J Neurosurg 2024; 38:503-509. [PMID: 33779461 DOI: 10.1080/02688697.2021.1905773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/16/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Studies on surgical site infection (SSI) in adult neurosurgery have presented all subtypes of SSIs as the general 'SSI'. Given that SSIs constitute a broad range of infections, we hypothesized that clinical outcomes and management vary based on SSI subtype. METHODS A retrospective analysis of all neurosurgical SSI from 2012-2019 was conducted at a tertiary care institution. SSI subtypes were categorized as deep and superficial incisional SSI, brain, dural or spinal abscesses, meningitis or ventriculitis, and osteomyelitis. RESULTS 9620 craniotomy, shunt, and fusion procedures were studied. 147 procedures (1.5%) resulted in postoperative SSI. 87 (59.2%) of these were associated with craniotomy, 36 (24.5%) with spinal fusion, and 24 (16.3%) with ventricular shunting. Compared with superficial incisional primary SSI, rates of reoperation to treat SSI were highest for deep incisional primary SSI (91.2% vs 38.9% for superficial, p < 0.001) and second-highest for intracranial SSI (90.9% vs 38.9%, p = 0.0001). Postoperative meningitis was associated with the highest mortality rate (14.9%). Compared with superficial incisional SSI, the rate of readmission for intracranial SSI was highest (57.6% vs 16.7%, p = 0.022). CONCLUSION Deep incisional and organ space SSI demonstrate a greater association with morbidity relative to superficial incisional SSI. Future studies should assess subtypes of SSI given these differences.
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Affiliation(s)
- Arjun R Adapa
- Medical School, University of Michigan, Ann Arbor, MI, USA
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Joseph R Linzey
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Badih J Daou
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
| | | | | | | | - Paul Park
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
- Department of Orthopedic Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, USA
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3
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Elbaroody M, Ezz A, Eldessouky AH, Hassan AAAN, Elsharkawy AA, Ali KB, Refaee EAE. Is It Possible to Eliminate Postoperative Shunt Infections?: Results of a Modified Hydrocephalus Clinical Research Network Protocol. J Neurol Surg A Cent Eur Neurosurg 2024; 85:32-38. [PMID: 36693411 DOI: 10.1055/s-0042-1760227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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.
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Affiliation(s)
- Mohammad Elbaroody
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Adham Ezz
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Amr Helmy Eldessouky
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Ahmed A Aziz N Hassan
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Ahmed Abbas Elsharkawy
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Khaled Bassim Ali
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Ehab Ahmed El Refaee
- Department of Neurosurgery, Cairo University, Kasr Alainy Faculty of Medicine, Cairo, Egypt
- Department of Neurosurgery, Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie. Sauerbruchstraße, Greifswald, Germany
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4
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Khalid SI, Deysher D, Khilwani H, Mirpuri P, Thomson K, Maynard M, Mehta AI. Gastrostomy Sequence With Ventriculoperitoneal Shunting-Does It Matter? Neurosurgery 2023; 93:1154-1159. [PMID: 37283524 DOI: 10.1227/neu.0000000000002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/12/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Neurological injury requiring ventriculoperitoneal shunt (VPS) placement often necessitates gastrostomy for nutritional support. The sequence of these procedures is debated over concerns for shunt infection and displacement requiring revisional surgery as a consequence of gastrostomy. OBJECTIVE To determine the optimal sequence of VPS shunt and gastrostomy tube placement in adults. METHODS In an all-payer database, adult patients undergoing gastrostomy and VPS placement were identified within 15 days between January 2010 and October 2021. Patients were categorized as receiving gastrostomy before, on the same day as, or after shunt placement. The primary outcomes of this study were rates of revision and infection. All outcomes were evaluated within 30 months after index shunting. RESULTS In total, 3015 patients were identified as undergoing VPS and gastrostomy procedures within 15 days. After a 1:1:1 match, 1080 patient records were analyzed. Revision rates at 30 months were significantly lower among patients who received VPS and gastrostomy procedures on the same day compared with gastrostomy after VPS (odds ratio [OR] 0.61, 95% CI 0.39-0.96). In addition, patients who received gastrostomy before VPS compared with those after had lower revision rates (OR 0.61, 95% CI 0.39-0.96) and infection (OR 0.46, 95% CI 0.21-0.99). No significant differences were noted in mechanical complication or shunt displacement rates. CONCLUSION Patients requiring VPS and gastrostomy may benefit from undergoing both procedures concurrently or with gastrostomy before VPS placement, secondary to lower revision rates. Patients undergoing gastrostomy before VPS have the added benefit of decreased infection rates.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago , Illinois , USA
| | - Daniel Deysher
- Department of Neurosurgery, University of Illinois at Chicago, Chicago , Illinois , USA
| | - Harsh Khilwani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago , Illinois , USA
| | - Pranav Mirpuri
- Chicago Medical School, Rosalind Franklin School of Medicine and Science, North Chicago , Illinois , USA
| | - Kyle Thomson
- Chicago Medical School, Rosalind Franklin School of Medicine and Science, North Chicago , Illinois , USA
| | - Marquis Maynard
- Case Western Reserve School of Medicine, Cleveland , Ohio , USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago , Illinois , USA
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5
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Okoli ML, Ishiekwene CC, Madhu C, Alosi M. A rare case of ventriculoperitoneal shunt co-infection with Brevibacterium and Corynebacterium minutissimum organisms. IDCases 2023; 34:e01920. [PMID: 37954168 PMCID: PMC10637911 DOI: 10.1016/j.idcr.2023.e01920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023] Open
Abstract
Ventriculoperitoneal (VP) shunt infections are associated with increased risk of morbidity and mortality from complications such as meningitis, ventriculitis, shunt malfunction and in some cases, recurrence of infection. Brevibacterium and Corynebacterium are gram positive organisms that are rarely implicated in VP shunt infections but are more commonly associated with colonization of dialysis and central venous catheters. Typical microbiological isolates in VP shunt infections include Staphylococcus aureus, Staphylococcus epidermidis and gram-negative rods. Here, we describe the case of a young woman who had VP shunt placement for over a decade without any history of infection, and now presented with new-onset VP shunt co-infection with Brevibacterium and Corynebacterium organisms.
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Affiliation(s)
- Menkeoma Laura Okoli
- Internal Medicine Department, Christus Health/Texas A&M University, 700 E Marshall Avenue, Longview, TX 75601, USA
| | | | - Chiluveri Madhu
- Internal Medicine Department, Christus Health/Texas A&M University, USA
| | - Marlena Alosi
- Internal Medicine Department, Christus Health/Texas A&M University, USA
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6
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Sunderland GJ, Conroy EJ, Nelson A, Gamble C, Jenkinson MD, Griffiths MJ, Mallucci CL. Factors affecting ventriculoperitoneal shunt revision: a post hoc analysis of the British Antibiotic and Silver Impregnated Catheter Shunt multicenter randomized controlled trial. J Neurosurg 2023; 138:483-493. [PMID: 36303476 DOI: 10.3171/2022.4.jns22572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The British Antibiotic and Silver Impregnated Catheter Shunt (BASICS) trial established level I evidence of the superiority of antibiotic-impregnated catheters in the prevention of infection of newly implanted ventriculoperitoneal shunts (VPSs). A wealth of patient, shunt, and surgery-specific data were collected from trial participants beyond that of the prespecified trial objectives. METHODS This post hoc analysis of the BASICS survival data explores the impact of patient age, hydrocephalus etiology, catheter type, valve type, and previous external ventricular drain on the risk of infection or mechanical failure. Time to failure was analyzed using Fine and Gray survival regression models for competing risk. RESULTS Among 1594 participants, 75 patients underwent revision for infection and 323 for mechanical failure. Multivariable analysis demonstrated an increased risk of shunt infection associated with patient ages < 1 month (subdistribution hazard ratio [sHR] 4.48, 95% CI 2.06-9.72; p < 0.001) and 1 month to < 1 year (sHR 2.67, 95% CI 1.27-5.59; p = 0.009), as well as for adults with posthemorrhagic hydrocephalus (sHR 2.75, 95% CI 1.21-6.26; p = 0.016). Age ≥ 65 years was found to be independently associated with reduced infection risk (sHR 0.26, 95% CI 0.10-0.69; p = 0.007). Antibiotic-impregnated catheter use was also associated with reduced infection risk (sHR 0.43, 95% CI 0.22-0.84; p = 0.014). Independent risk factors predisposing to mechanical failure were age < 1 month (sHR 1.51, 95% CI 1.03-2.21; p = 0.032) and 1 month to < 1 year (sHR 1.31, 95% CI 0.95-1.81; p = 0.046). Age ≥ 65 years was demonstrated to be the only independent protective factor against mechanical failure risk (sHR 0.64, 95% CI 0.40-0.94; p = 0.024). CONCLUSIONS Age is the predominant risk for VPS revision for infection and/or mechanical failure, with neonates and infants being the most vulnerable.
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Affiliation(s)
- Geraint J Sunderland
- 1Department of Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool.,2Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool.,3Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool
| | | | - Alexandra Nelson
- 1Department of Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool.,5University Hospitals Bristol and Weston NHS Trust, Bristol
| | - Carrol Gamble
- 4Liverpool Clinical Trials Centre, University of Liverpool
| | - Michael D Jenkinson
- 2Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool.,6Institute of Systems, Molecular and Integrative Biology, University of Liverpool; and
| | - Michael J Griffiths
- 3Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool.,7Department of Paediatric Neurology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Conor L Mallucci
- 1Department of Paediatric Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool
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7
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Sharma R, Johnson RH, David GR, Rahimifar M, Heidari A. A Case of Coccidioidal Meningitis With Biofilm Obstructing VP Shunt Due to Cutibacterium acnes. J Investig Med High Impact Case Rep 2023; 11:23247096231159810. [PMID: 36905317 PMCID: PMC10009585 DOI: 10.1177/23247096231159810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Herein described is a case of biofilm obstructing ventriculoperitoneal shunt due to Cutibacteirum acnes infection in a patient with coccidioidal meningitis. Cutibacterium acnes infects and obstructs cerebral shunts by the production of biofilm; however, diagnosis is usually missed by routine aerobic cultures. Obtaining anaerobic cultures routinely in patients with foreign body implants leading to central nervous system infections could prevent a missed diagnosis of this pathogen. Penicillin G is the first-line treatment.
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Affiliation(s)
- Rupam Sharma
- Kern Medical, Bakersfield, CA, USA.,University of California, Los Angeles, USA
| | - Royce H Johnson
- Kern Medical, Bakersfield, CA, USA.,University of California, Los Angeles, USA
| | | | | | - Arash Heidari
- Kern Medical, Bakersfield, CA, USA.,University of California, Los Angeles, USA
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8
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M M, F C, M G, S F, A B. How to: diagnose inborn errors of intrinsic and innate immunity to viral, bacterial, mycobacterial and fungal infections. Clin Microbiol Infect 2022; 28:1441-1448. [DOI: 10.1016/j.cmi.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/04/2022] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
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9
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Sharma S, Dziugan K, Kucera A, Lam S, DeCuypere M. COVID-19 Impact on Cerebrospinal Fluid Diversion: A Single Institution Experience. Cureus 2022; 14:e26578. [PMID: 35936143 PMCID: PMC9351828 DOI: 10.7759/cureus.26578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
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10
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Zhao W, Libera M, Prysak M, Katz J, De Stefano L. An in vitro model of microbial contamination in the operating room. J Biomed Mater Res B Appl Biomater 2022; 110:2472-2479. [PMID: 35620867 DOI: 10.1002/jbm.b.35104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/12/2022] [Accepted: 05/09/2022] [Indexed: 11/08/2022]
Abstract
Infection associated with tissue-contacting biomedical devices is a compelling clinical problem initiated by the microbial colonization of the device surface. Among the possible sources of contaminating bacteria is the operating room (OR) itself, where viable bacteria in the atmosphere can sediment onto a device surface intraoperatively. We have developed an aerosolizing system that can reproducibly spray small quantities of aerosolized bacteria onto a surface to mimic OR contamination. This paper describes the design of the system and characterizes key aspects associated with its operation. The area density of sprayed bacteria is on the order of 102 /cm2 . Using titanium (Ti) alloy coupons as test substrates contaminated by staphylococci, we quantify the fraction of bacteria that are well adhered to the substrate, those that can be removed by sonication, and those that are not recovered after spraying. Despite the relatively low levels of surface contamination, we furthermore show that such a model is able to demonstrate a statistically significant reduction in colonization of Ti coupons modified by antimicrobial quaternary ammonium compounds relative to unmodified controls.
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Affiliation(s)
- Wenhan Zhao
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, New Jersey, USA
| | - Matthew Libera
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, New Jersey, USA
| | | | - Jordan Katz
- Orthobond Corporation, Princeton, New Jersey, USA
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11
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Alkosha HM, Mohammed MIR, El Shokhaiby UM, Amen MM. A Proposed Protective Protocol Predicting Reduction of Shunt Infection. World Neurosurg 2022; 164:e1049-e1057. [PMID: 35643405 DOI: 10.1016/j.wneu.2022.05.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify the best protective interventions against shunt infection and, hence, to find an appropriate protocol assumed to be associated with reduction of infection rates. METHODS A combined prospective-retrospective cohort study was conducted over a period of 5 years in 3 referral hospitals. Twelve interventions against infection practiced by blinded surgeons during ventriculoperitoneal shunt operations were surveyed and their association with the outcome of interest (i.e., shunt infection) was tested. Interventions proved to be associated with the outcome entered a multivariate logistic regression to identify the protective interventions. RESULTS Among a total of 392 cases, shunt infection was diagnosed in 11.5% with a median onset of 55 days. Patients' demographics, etiology of hydrocephalus, shunt-related factors, and type of preoperative antibiotics were not associated with shunt infection. Two-thirds of infected shunts revealed Staphylococcus species. Among the tested interventions, double-gloving and device and wound irrigation using vancomycin solution and the use of incision adhesive drapes proved to exhibit a significant protective effect against shunt infection, whereas operative time <40 minutes revealed a marginal protective benefit. CONCLUSIONS Shunt infection is a significant complication that occurs early during the first 2 months after surgery. According to the study findings, an appropriate protocol against shunt infection is assumed to be composed of double-gloving, device and wound irrigation using vancomycin solution, and the use of incision adhesive drapes. Reduced operative time had a beneficial effect against shunt infection, although it was of marginal significance in the current study.
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12
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Bastian RA, Pramusinto H, Basuki E, Marianne M. Ventriculoperitoneal Shunt Infection: A Study about Age as a Risk Factor in Hydrocephalus Pediatrics. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Shunt infection is one of the dreaded and serious complications following ventriculoperitoneal shunt (VP shunt) insertion, especially in a pediatric population. Numerous risk factors have been identified, particularly in developing countries, indicating that age may play an essential element in the pathogenesis of shunt infection, typically in patients <1-year-old. However, a few research demonstrate the inverse result.
AIM: The purpose of this was to determine the relationship between age and shunt infection so that it can be taken into consideration when performing VP shunt insertion.
METHODS: From January 2017 to December 2019, 98 pediatric patients with hydrocephalus who underwent VP shunt insertion were retrospectively reviewed to determine the relationship between age and shunt infection. We evaluated the microbiology results and management of shunt infection in patients with shunt infection.
RESULTS: Fifteen (15.15%) of 98 patients developed shunt infection. Patients aged >3–6 months had a significantly increased risk of shunt infection (p = 0.04; RR = 4.15; CI 95% = 1.19–14.45). Staphylococcus aureus was the most frequently encountered pathogen in pediatric patients with shunt infection (53.3%), and the most common management for shunt infection was complete removal of the shunt and systemic antibiotics followed by re-insertion of the shunt after the cerebrospinal fluid was sterile (46.6%).
CONCLUSION: We conclude that age, especially those aged >3–6 months, has a significantly higher risk of shunt infection in pediatric patients.
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13
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Yang Q, Enríquez Á, Devathasan D, Thompson CA, Nayee D, Harris R, Satoski D, Obeng-Gyasi B, Lee A, Bentley RT, Lee H. Application of magnetically actuated self-clearing catheter for rapid in situ blood clot clearance in hemorrhagic stroke treatment. Nat Commun 2022; 13:520. [PMID: 35082280 PMCID: PMC8791973 DOI: 10.1038/s41467-022-28101-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 01/06/2022] [Indexed: 11/08/2022] Open
Abstract
Maintaining the patency of indwelling drainage devices is critical in preventing further complications following an intraventricular hemorrhage (IVH) and other chronic disease management. Surgeons often use drainage devices to remove blood and cerebrospinal fluid but these catheters frequently become occluded with hematoma. Using an implantable magnetic microactuator, we created a self-clearing catheter that can generate large enough forces to break down obstructive blood clots by applying time-varying magnetic fields. In a blood-circulating model, our self-clearing catheters demonstrated a > 7x longer functionality than traditional catheters (211 vs. 27 min) and maintained a low pressure for longer periods (239 vs. 79 min). Using a porcine IVH model, the self-clearing catheters showed a greater survival rate than control catheters (86% vs. 0%) over the course of 6 weeks. The treated animals also had significantly smaller ventricle sizes 1 week after implantation compared to the control animals with traditional catheters. Our results suggest that these magnetic microactuator-embedded smart catheters can expedite the removal of blood from the ventricles and potentially improve the outcomes of critical patients suffering from often deadly IVH.
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Affiliation(s)
- Qi Yang
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
- School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, 47907, USA
| | - Ángel Enríquez
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA
| | - Dillon Devathasan
- College of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA
| | - Craig A Thompson
- College of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA
| | - Dillan Nayee
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
| | - Ryan Harris
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
| | - Douglas Satoski
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
| | - Barnabas Obeng-Gyasi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA
| | - Albert Lee
- Goodman Campbell Brain and Spine, Indianapolis, IN, 46202, USA
| | - R Timothy Bentley
- College of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA
| | - Hyowon Lee
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA.
- Center for Implantable Devices, Purdue University, West Lafayette, IN, 47907, USA.
- Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA.
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14
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Owusu‐Adjei B, Ogagan C, Smith J, Luiselli G, Johnson MD. Bacterial translocation as a cause of ventriculoperitoneal shunt infection: A case report. Clin Case Rep 2022; 10:e04921. [PMID: 35035957 PMCID: PMC8752371 DOI: 10.1002/ccr3.4921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/30/2021] [Accepted: 09/25/2021] [Indexed: 11/17/2022] Open
Abstract
Bacterial translocation as a mechanism of distal catheter infection may play a larger role in ventriculoperitoneal shunt infections than previously recognized.
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Affiliation(s)
- Brittany Owusu‐Adjei
- Department of Neurological SurgeryUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
- UMass Memorial HealthWorcesterMassachusettsUSA
| | - Charles Ogagan
- Department of Neurological SurgeryUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Jordan Smith
- Department of Neurological SurgeryUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Gabrielle Luiselli
- Department of Neurological SurgeryUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Mark D. Johnson
- Department of Neurological SurgeryUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
- UMass Memorial HealthWorcesterMassachusettsUSA
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15
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Lopacinski AB, Guy KM, Burgess JR, Collins JN. Differences in Outcome Between Open vs Laparoscopic Insertion of Ventriculoperitoneal Shunts. Am Surg 2021; 88:716-721. [PMID: 34734537 DOI: 10.1177/00031348211050594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Abdominal access during ventriculoperitoneal (VP) shunt insertion has historically been obtained by neurosurgeons via an open abdominal approach. With recent advances in laparoscopy, neurosurgeons frequently consult general surgery for aid during the procedure. The goal of this study is to identify if laparoscopic assistance improves the overall outcomes of the procedure. METHODS This retrospective study included all patients who underwent open or laparoscopic VP shunt placement between September 2012 and August 2020 at our tertiary referral hospital. Patient demographics, comorbidities, prior history of abdominal surgery, open vs. laparoscopic insertion, operation time, and complications within 30 days were obtained. RESULTS Neurosurgery placed 107 shunts using an open abdominal technique and general surgery placed 78 using laparoscopy. The average OR time in minutes was 75.5 minutes for the open cohort and 61.8 for the laparoscopic cohort (p = 0.006). In patients without a history of abdominal surgery, the average OR time in minutes was 79.4 in the open cohort and 57.1 in the laparoscopic cohort (p = 0.015). The postoperative shunt infection rate was 10.2% in the open group and 3.8% in the laparoscopic group (p = 0.077). DISCUSSION Laparoscopic placement of VP shunts is a reasonable alternative to open placement and results in shorter OR times. There is also a trend toward few infections in the laparoscopic placement. There appears to be an advantage with a team approach and laparoscopic placement of the peritoneal portion of the shunt.
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Affiliation(s)
- Aaron B Lopacinski
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kevin M Guy
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jessica R Burgess
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jay N Collins
- Department of Surgery, 6040Eastern Virginia Medical School, Norfolk, VA, USA
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Lakomkin N, Hadjipanayis CG. In Reply: The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement. Neurosurgery 2021; 89:E104. [PMID: 33887771 DOI: 10.1093/neuros/nyab145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai Mount Sinai Health System New York, New York, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai Mount Sinai Health System New York, New York, USA
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17
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Fu X, Chen Y, Duan W, Yang H, Xu J, Cheng X, Zhang H. Ventriculoperitoneal shunt malfunction diagnosis based on substance dilution. Medicine (Baltimore) 2021; 100:e26770. [PMID: 34397823 PMCID: PMC8341280 DOI: 10.1097/md.0000000000026770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/05/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Current methods for the diagnosis of ventriculoperitoneal (VP) shunt malfunction lack specific standards; therefore, it may be missed or misdiagnosed. Hence, providing a reliable diagnostic method will help improve the accuracy of preoperative decision-making. Therefore, the aim of the study was to provide a new method for the diagnosis of VP shunt malfunction. METHODS After in vitro testing, we enrolled a total of 12 patients with VP shunt malfunction. Before revision surgery, 0.1 mL of a 5% sodium valproate (SV) solution was injected into the reservoir; 0.1 mL of the cerebrospinal fluid (CSF) was withdrawn 20 minutes later from the reservoir to measure the SV concentration. The process was repeated on the seventh day after surgery and compared with the preoperative results. RESULTS The mean ± standard deviation preoperative SV concentration in the cerebrospinal fluid was greater than the postoperative concentration (5967.8 ± 1281.3 vs 391.1 ± 184.6 μg/mL, P = .001). CONCLUSION The proposed method is a reliable, safe, and relatively simple alternative for the diagnosis of VP shunt malfunction and further provides a reference for treatment.
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Korshoj LE, Shi W, Duan B, Kielian T. The Prospect of Nanoparticle Systems for Modulating Immune Cell Polarization During Central Nervous System Infection. Front Immunol 2021; 12:670931. [PMID: 34248952 PMCID: PMC8260670 DOI: 10.3389/fimmu.2021.670931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/03/2021] [Indexed: 01/20/2023] Open
Abstract
The blood-brain barrier (BBB) selectively restricts the entry of molecules from peripheral circulation into the central nervous system (CNS) parenchyma. Despite this protective barrier, bacteria and other pathogens can still invade the CNS, often as a consequence of immune deficiencies or complications following neurosurgical procedures. These infections are difficult to treat since many bacteria, such as Staphylococcus aureus, encode a repertoire of virulence factors, can acquire antibiotic resistance, and form biofilm. Additionally, pathogens can leverage virulence factor production to polarize host immune cells towards an anti-inflammatory phenotype, leading to chronic infection. The difficulty of pathogen clearance is magnified by the fact that antibiotics and other treatments cannot easily penetrate the BBB, which requires extended regimens to achieve therapeutic concentrations. Nanoparticle systems are rapidly emerging as a promising platform to treat a range of CNS disorders. Nanoparticles have several advantages, as they can be engineered to cross the BBB with specific functionality to increase cellular and molecular targeting, have controlled release of therapeutic agents, and superior bioavailability and circulation compared to traditional therapies. Within the CNS environment, therapeutic actions are not limited to directly targeting the pathogen, but can also be tailored to modulate immune cell activation to promote infection resolution. This perspective highlights the factors leading to infection persistence in the CNS and discusses how novel nanoparticle therapies can be engineered to provide enhanced treatment, specifically through modulation of immune cell polarization.
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Affiliation(s)
- Lee E Korshoj
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Wen Shi
- Mary & Dick Holland Regenerative Medicine Program, Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Bin Duan
- Mary & Dick Holland Regenerative Medicine Program, Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Tammy Kielian
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, United States
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Goda R, Ganeshkumar A, Katiyar V, Sharma R, Gurjar HK, Chaturvedi A, Sahu R, Rai HIS, Vora Z. Efficacy of antimicrobial medicated ventricular catheters: a network meta-analysis with trial sequential analysis. Neurosurg Rev 2021; 45:91-102. [PMID: 34009522 DOI: 10.1007/s10143-021-01532-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/20/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
There is paucity of evidence regarding relative performance of antibiotic-medicated (AM), silver-medicated (SM) and non-medicated (NM) ventricular catheters in controlling infection rate. We aim to quantitatively synthesize the current evidence after addition of the three-armed British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial, understand the need for further evidence using trial sequential analysis (TSA) and incorporate the indirect evidence using network meta-analysis (NMA). Randomized controlled trials (RCTs) comparing AM, SM and NM ventriculoperitoneal shunt (VPS) or external ventricular drain (EVD) were included. Antibiotic-medicated VPS show a significantly lower infection rate as compared to non-medicated VPS (RR 0.44; 95% CI: 0.27-0.73; p = 0.001), however, TSA reveals need for further evidence. SM including both EVD as well as VPS were found to be inferior to AM while no significant difference was found in comparison to the NM catheters. In NMA for VPS, the AM were found to be significantly better than SM (RR 0.41, 95% CI: 0.22-0.75) as well as NM (RR 0.42; 95% CI: 0.25-0.71) with a SUCRA of 99.8% and a mean rank of 1. However, antibiotic medicated shunts did not show a statistically significant association with reoperation rate (RR 0.99; 95% CI:0.81-1.20; p = 0.9) with no further need for evidence as per TSA.
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Affiliation(s)
- Revanth Goda
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Ganeshkumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Varidh Katiyar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Kumar Gurjar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Aprajita Chaturvedi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Roshan Sahu
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Zainab Vora
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Abstract
PURPOSE OF REVIEW We have highlighted the recent advances in infection in neurocritical care. RECENT FINDINGS Central nervous system (CNS) infections, including meningitis, encephalitis and pyogenic brain infections represent a significant cause of ICU admissions. We underwent an extensive review of the literature over the last several years in order to summarize the most important points in the diagnosis and treatment of severe infections in neurocritical care. SUMMARY Acute brain injury triggers an inflammatory response that involves a complex interaction between innate and adaptive immunity, and there are several factors that can be implicated, such as age, genetic predisposition, the degree and mechanism of the injury, systemic and secondary injury and therapeutic interventions. Neuroinflammation is a major contributor to secondary injury. The frequent and challenging presence of fever is a common denominator amongst all neurocritical care patients.
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Affiliation(s)
- Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Alan Blake
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
| | - Daniel Collins
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital
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21
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Cuff SM, Merola JP, Twohig JP, Eberl M, Gray WP. Toll-like receptor linked cytokine profiles in cerebrospinal fluid discriminate neurological infection from sterile inflammation. Brain Commun 2020; 2:fcaa218. [PMID: 33409494 PMCID: PMC7772097 DOI: 10.1093/braincomms/fcaa218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/12/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Rapid determination of an infective aetiology causing neurological inflammation in the cerebrospinal fluid can be challenging in clinical practice. Post-surgical nosocomial infection is difficult to diagnose accurately, as it occurs on a background of altered cerebrospinal fluid composition due to the underlying pathologies and surgical procedures involved. There is additional diagnostic difficulty after external ventricular drain or ventriculoperitoneal shunt surgery, as infection is often caused by pathogens growing as biofilms, which may fail to elicit a significant inflammatory response and are challenging to identify by microbiological culture. Despite much research effort, a single sensitive and specific cerebrospinal fluid biomarker has yet to be defined which reliably distinguishes infective from non-infective inflammation. As a result, many patients with suspected infection are treated empirically with broad-spectrum antibiotics in the absence of definitive diagnostic criteria. To begin to address these issues, we examined cerebrospinal fluid taken at the point of clinical equipoise to diagnose cerebrospinal fluid infection in 14 consecutive neurosurgical patients showing signs of inflammatory complications. Using the guidelines of the Infectious Diseases Society of America, six cases were subsequently characterized as infected and eight as sterile inflammation. Twenty-four contemporaneous patients with idiopathic intracranial hypertension or normal pressure hydrocephalus were included as non-inflamed controls. We measured 182 immune and neurological biomarkers in each sample and used pathway analysis to elucidate the biological underpinnings of any biomarker changes. Increased levels of the inflammatory cytokine interleukin-6 and interleukin-6-related mediators such as oncostatin M were excellent indicators of inflammation. However, interleukin-6 levels alone could not distinguish between bacterially infected and uninfected patients. Within the patient cohort with neurological inflammation, a pattern of raised interleukin-17, interleukin-12p40/p70 and interleukin-23 levels delineated nosocomial bacteriological infection from background neuroinflammation. Pathway analysis showed that the observed immune signatures could be explained through a common generic inflammatory response marked by interleukin-6 in both nosocomial and non-infectious inflammation, overlaid with a toll-like receptor-associated and bacterial peptidoglycan-triggered interleukin-17 pathway response that occurred exclusively during infection. This is the first demonstration of a pathway dependent cerebrospinal fluid biomarker differentiation distinguishing nosocomial infection from background neuroinflammation. It is especially relevant to the commonly encountered pathologies in clinical practice, such as subarachnoid haemorrhage and post-cranial neurosurgery. While requiring confirmation in a larger cohort, the current data indicate the potential utility of cerebrospinal fluid biomarker strategies to identify differential initiation of a common downstream interleukin-6 pathway to diagnose nosocomial infection in this challenging clinical cohort.
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Affiliation(s)
- Simone M Cuff
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Joseph P Merola
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Jason P Twohig
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthias Eberl
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - William P Gray
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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22
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Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey. Childs Nerv Syst 2020; 36:2949-2960. [PMID: 32519130 DOI: 10.1007/s00381-020-04699-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment. OBJECTIVE We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures. METHODS A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment. RESULTS A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 109/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively. DISCUSSION Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.
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A Plastic-neuro Effort: Vascularized Soft-tissue Coverage for Hostile Wound Bed with Multiple Ventricular Shunt Failures. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3257. [PMID: 33299719 PMCID: PMC7722575 DOI: 10.1097/gox.0000000000003257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022]
Abstract
Cerebral ventricular shunt placements are the most common neurosurgical procedure performed today, which play a life-long role in the care of patients with hydrocephalus. Complication rates requiring shunt replacement are as high as 25%, and the potential need for multiple revisions throughout a patient’s life may result in the formation of scar tissue and compromised wound healing. Without addition of vascularized tissue, patients with scalp scarring and impaired wound healing then enter a cycle of impaired skin closure followed by shunt infection, failure, and revision with little promise of long-term operative or therapeutic success. This plastics-neuro collaboration is the first known report of a free vastus lateralis muscle flap for coverage of a cerebral ventricular shunt, in a patient with congenital hydrocephalus and 17 previous ventricular shunts revisions due to infections and soft tissue exposure from scarring and a hostile wound bed. In the setting of extensive scarring, the free vascularized muscle flap provides soft tissue and vascular supply capable of promoting wound healing, maintaining scalp integrity, and reducing the incidence of shunt infection and the subsequent need for future revision, as supported by the complication-free status of the same patient now 16 months since the date of operation.
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Couturier MR, Bard JD. Direct-from-Specimen Pathogen Identification: Evolution of Syndromic Panels. Clin Lab Med 2020; 39:433-451. [PMID: 31383267 PMCID: PMC7131637 DOI: 10.1016/j.cll.2019.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Marc Roger Couturier
- ARUP Laboratories, University of Utah, 500 Chipeta Way, Salt Lake City, UT 84108, USA.
| | - Jennifer Dien Bard
- Microbiology and Virology Laboratories, Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, University of Southern California, 4650 Sunset Boulevard MS#32, Los Angeles, CA 90027, USA
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25
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Al-Sharydah AM, Abu Melha YA, Al-Suhibani SS, Alojan AA, Al-Taei TH, Alfawaz II, AlShammari LT, Al-Jubran SA, Ammar AS. Rates of cerebrospinal fluid infection and the causative organisms following shunt procedures in Saudi Arabia. A retrospective study based on radiological findings. Saudi Med J 2020; 41:607-613. [PMID: 32518927 PMCID: PMC7502950 DOI: 10.15537/smj.2020.6.25095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives: To assess the incidence of infection following various cerebrospinal fluid (CSF) shunt procedures among patients with hydrocephalus and related conditions, based on the age of the patient, and to determine the types of pathogens responsible for shunt infections. Methods: This retrospective single center study reviewed the records of patients with culture-confirmed CSF shunt infection diagnosed between January 2012 and December 2017. Cases without central nervous system imaging investigations were excluded. Results: The incidence rate of shunt-related infections was 32.2%. Among the 189 patients whose records were included, Staphylococcus epidermidis (47.5%) and Acinetobacter baumannii (18%) were the most common causative organisms. The incidence of postoperative infection was higher among those who underwent external ventricular drain procedures (65%) than among those who underwent ventriculoperitoneal shunt procedures (24%). There were no intraoperative deaths. However, the postoperative death rate was 12.2% during hospital stay (mean duration = 9 days); 2% of these deaths occurred after shunt removal. Conclusion: The incidence of infections after CSF shunt procedures was high in our tertiary academic hospital during the study period, compared to those reported in similar clinical settings and before developing a detailed standardized protocol for infection control. Although gram-negative organisms were the most prevalent cause of CSF infections, S. epidermidis (a gram-positive organism) was the most commonly encountered causative agent. Shunt protocols should be implemented to address perioperative shortcomings and to reduce overall mortality and morbidity.
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Affiliation(s)
- AbdulAziz M Al-Sharydah
- Diagnostic & Interventional Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, AlKhobar, Kingdom of Saudi Arabia. E-mail.
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26
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Xiao X, Zhao W, Liang J, Sauer K, Libera M. Self-defensive antimicrobial biomaterial surfaces. Colloids Surf B Biointerfaces 2020; 192:110989. [PMID: 32361372 PMCID: PMC7308212 DOI: 10.1016/j.colsurfb.2020.110989] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/11/2020] [Accepted: 03/23/2020] [Indexed: 01/16/2023]
Abstract
Self-defensive biomaterial surfaces are being developed in order to mitigate infection associated with tissue-contacting biomedical devices. Such infection occurs when microbes colonize the surface of a device and proliferate into a recalcitrant biofilm. A key intervention point centers on preventing the initial colonization. Incorporating antimicrobials within a surface coating can be very effective, but the traditional means of antimicrobial delivery by continuous elution can often be counterproductive. If there is no infection, continuous elution creates conditions that promote the development of resistant microbes throughout the patient. In contrast, a self-defensive coating releases antimicrobial only when and only where there is a microbial challenge to the surface. Otherwise, the antimicrobial remains sequestered within the coating and does not contribute to the development of resistance. A self-defensive surface requires a local trigger that signals the microbial challenge. Three such triggers have been identified as: (1) local pH lowering; (2) local enzyme release; and (3) direct microbial-surface contact. This short review highlights the need for self-defensive surfaces in the general context of the device-infection problem and then reviews key biomaterials developments associated with each of these three triggering mechanisms.
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Affiliation(s)
- Xixi Xiao
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Wenhan Zhao
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Jing Liang
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Karin Sauer
- Binghamton Biofilm Research Center (BBRC), Binghamton University Binghamton, NY USA
| | - Matthew Libera
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, NJ, USA.
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27
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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; 36:401-409. [PMID: 31455997 DOI: 10.1007/s00381-019-04357-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/15/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Shunting for hydrocephalus can lead to improvement in the quality of life although the latter has been subdued by complications like shunt infection. Established protocols have contributed to the reduction of ventriculoperitoneal shunt (VPS) infections. Previously, we retrospectively demonstrated a low infection rate despite some of the protocol recommendations not being implemented. The aim of this study was to prospectively establish the incidence of shunt infection in the early post-shunt period following our protocol and elucidate on associated risk factors. PATIENTS AND METHODS A multicenter prospective descriptive cohort study of consecutive 209 under-5 children requiring VPS for hydrocephalus was conducted between January 2013 and November 2018. An innovative protocol insisting on intermittent application of povidone-iodine on the skin during the operation was implemented. The patients were followed-up for 3 months post-surgery. RESULTS Included were 211 VPS procedures performed on 209 children. The median age was 9 months and 84 were males. Hydrocephalus was non-communicative in 72.0% and aqueductal stenosis was its most frequent cause (84.9%). Most surgeries were performed in the morning (90.5%), electively (95.3%), and for the first time (91%). The median duration of surgery was 65 min. Shunt infection rate was 1.9% (n = 4) (95% CI 0.7 to 5.0%) per procedure. CONCLUSION The observed infection rate was low. This suggests that the protocol followed captured the most critical components necessary to ensure low infection rates and that simple measures implemented in economically challenged environments may achieve internationally acceptable infection rates.
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Affiliation(s)
- Kazadi K N Kalangu
- Neurosurgery Division, Department of Surgery, University Of Zimbabwe, Harare, Zimbabwe.
| | - Ignatius N Esene
- Neurosurgery Division, Department of Surgery, University Of Bamenda, Bamenda, Cameroon
| | - Maximillian Dzowa
- Neurosurgery Division, Department of Surgery, University Of Zimbabwe, Harare, Zimbabwe
| | - Aaron Musara
- Neurosurgery Division, Department of Surgery, University Of Zimbabwe, Harare, Zimbabwe
| | - Jeff Ntalaja
- Department of Neurosurgery, University of Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Aliou K Badra
- Neurosurgical Unit, Medipark/Oshakati Hospital, University of Namibia, Windhoek, Namibia
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Dorresteijn KRIS, Brouwer MC, Jellema K, van de Beek D. Bacterial external ventricular catheter-associated infection. Expert Rev Anti Infect Ther 2020; 18:219-229. [DOI: 10.1080/14787210.2020.1717949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Matthijs C. Brouwer
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kaestner S, Fraij A, Fass J, Deinsberger W. Ventriculoperitoneal Shunt Infections Cause Acute Abdomen and Peritonitis: A Case Series. J Surg Res 2020; 248:153-158. [PMID: 31901642 DOI: 10.1016/j.jss.2019.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/14/2019] [Accepted: 11/26/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with ventriculoperitoneal shunt (VPS) often present to emergency departments with acute abdomen. It is challenging to distinguish between the abdominal problems caused by a VPS and acute surgical abdomen having another cause because VPS infections occasionally cause peritonitis. The frequencies and clinical features of acute abdomen caused by VPS infection are unknown. METHODS This was a retrospective analysis of all patients with a VPS who presented with acute abdomen to emergency department for a 10-year period. Clinical data, diagnostic workflow, and subsequent treatment were assessed using patient medical records. RESULTS In total, 1679 patients presented with acute abdomen; of these, 24 (1.4%) had a VPS at the time of presentation. Of the 24 patients, 12 had an acute surgical abdomen related to gastrointestinal sources with subsequent therapy. In the remaining 12 patients (50%), peritonitis was caused by a VPS infection; seven of these had erroneous abdominal surgeries because of misdiagnosis. Patients with shunt infections as a source of peritonitis underwent shunt surgeries within the past 10 wk (mean, 58 d). Patients with an acute surgical abdomen with gastrointestinal sources had their most recent shunt surgery at a mean of 4.7 y before presentation to the emergency department. CONCLUSIONS Acute abdomen and peritonitis are challenging in the presence of a VPS. Shunt infections frequently mimic acute surgical abdomen and may lead to misdiagnosis, unnecessary diagnostic procedures, unnecessary surgery, and delay in receiving the appropriate treatment. Shunt surgery in recent patient history is suggestive of VPS infection, and a shunt tap should be performed to confirm the diagnosis.
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Affiliation(s)
- Stefanie Kaestner
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany; Kassel School of Medicine, University of Southampton, Southampton, UK.
| | - Amina Fraij
- Educational Science, Center for Teacher Education, University of Giessen, Giessen Germany
| | - Juegen Fass
- Department of General and Visceral Surgery, Klinikum Kassel, Kassel, Germany
| | - Wolfgang Deinsberger
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany; Kassel School of Medicine, University of Southampton, Southampton, UK
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Identification of Potential Cerebrospinal Fluid Biomarkers To Discriminate between Infection and Sterile Inflammation in a Rat Model of Staphylococcus epidermidis Catheter Infection. Infect Immun 2019; 87:IAI.00311-19. [PMID: 31262978 PMCID: PMC6704599 DOI: 10.1128/iai.00311-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/18/2019] [Indexed: 12/14/2022] Open
Abstract
Staphylococcus epidermidis cerebrospinal fluid (CSF) shunt infection is a common complication of hydrocephalus treatment, creating grave neurological consequences for patients, especially when diagnosis is delayed. The current method of diagnosis relies on microbiological culture; however, awaiting culture results may cause treatment delays, or culture may fail to identify infection altogether, so newer methods are needed. Staphylococcus epidermidis cerebrospinal fluid (CSF) shunt infection is a common complication of hydrocephalus treatment, creating grave neurological consequences for patients, especially when diagnosis is delayed. The current method of diagnosis relies on microbiological culture; however, awaiting culture results may cause treatment delays, or culture may fail to identify infection altogether, so newer methods are needed. To investigate potential CSF biomarkers of S. epidermidis shunt infection, we developed a rat model allowing for serial CSF sampling. We found elevated levels of interleukin-10 (IL-10), IL-1β, chemokine ligand 2 (CCL2), and CCL3 in the CSF of animals implanted with S. epidermidis-infected catheters compared to sterile controls at day 1 postinfection. Along with increased chemokine and cytokine expression early in infection, neutrophil influx was significantly increased in the CSF of animals with infected catheters, suggesting that coupling leukocyte counts with inflammatory mediators may differentiate infection from sterile inflammation. Mass spectrometry analysis revealed that the CSF proteome in sterile animals was similar to that in infected animals at day 1; however, by day 5 postinfection, there was an increase in the number of differently expressed proteins in the CSF of infected compared to sterile groups. The expansion of the proteome at day 5 postinfection was interesting, as bacterial burdens began to decline by this point, yet the CSF proteome data indicated that the host response remained active, especially with regard to the complement cascade. Collectively, these results provide potential biomarkers to distinguish S. epidermidis infection from sterile postoperative inflammation.
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Ocampo-Alzate JA, Botero-González N, Botero-Rojas LE, Morales-Alba N. Neuroinfección por Vibrio cholerae no O1/ no O139 secundaria a la derivación ventriculoperitoneal. Reporte de caso. IATREIA 2019. [DOI: 10.17533/udea.iatreia.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
La infección de la derivación ventriculoperitoneal es una de las complicaciones más frecuentes en este procedimiento. Vibrio cholerae O1 y O139 es una bacteria gram negativa conocida principalmente por ser la responsable del cólera epidémico. No obstante, existen serotipos no O1/no O139 capaces de causar afecciones extraintestinales, entre ellas se han reportado casos de neuroinfección. Presentamos el caso de una paciente con 9 meses de edad que posterior a la colocación de una derivación ventriculoperitoneal como tratamiento de hidrocefalia obstructiva congénita, presentó un cuadro de neuroinfección y el síndrome de malfunción valvular; se pudo aislar la Vibrio cholerae no O1/ no O139 en el líquido cefalorraquídeo y en la punta del catéter. Es el primer reporte en la literatura en la que se aísla la Vibrio cholerae no O1/ no O139 en líquido cefalorraquídeo secundario a infección de una derivación ventriculoperitoneal.
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Zhang H, Zhang J, Peng J, Hao X, Li G. The diagnosis of ventriculoperitoneal shunt malfunction by using phase-contrast cine magnetic resonance imaging. J Clin Neurosci 2019; 64:141-144. [DOI: 10.1016/j.jocn.2019.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 02/11/2019] [Accepted: 03/21/2019] [Indexed: 10/27/2022]
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Ventriculoperitoneal shunt catheter tract glioblastoma multiform concomitant to infection. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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CSF inflammatory markers differ in gram-positive versus gram-negative shunt infections. J Neuroinflammation 2019; 16:7. [PMID: 30626412 PMCID: PMC6325818 DOI: 10.1186/s12974-019-1395-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022] Open
Abstract
Background Cerebrospinal fluid (CSF) shunt placement is frequently complicated by bacterial infection. Shunt infection diagnosis relies on bacterial culture of CSF which can often produce false-negative results. Negative cultures present a conundrum for physicians as they are left to rely on other CSF indices, which can be unremarkable. New methods are needed to swiftly and accurately diagnose shunt infections. CSF chemokines and cytokines may prove useful as diagnostic biomarkers. The objective of this study was to evaluate the potential of systemic and CSF biomarkers for identification of CSF shunt infection. Methods We conducted a retrospective chart review of children with culture-confirmed CSF shunt infection at Children’s Hospital and Medical Center from July 2013 to December 2015. CSF cytokine analysis was performed for those patients with CSF in frozen storage from the same sample that was used for diagnostic culture. Results A total of 12 infections were included in this study. Patients with shunt infection had a median C-reactive protein (CRP) of 18.25 mg/dL. Median peripheral white blood cell count was 15.53 × 103 cells/mL. Those with shunt infection had a median CSF WBC of 332 cells/mL, median CSF protein level of 406 mg/dL, and median CSF glucose of 35.5 mg/dL. An interesting trend was observed with gram-positive infections having higher levels of the anti-inflammatory cytokine interleukin (IL)-10 as well as IL-17A and vascular endothelial growth factor (VEGF) compared to gram-negative infections, although these differences did not reach statistical significance. Conversely, gram-negative infections displayed higher levels of the pro-inflammatory cytokines IL-1β, fractalkine (CX3CL1), chemokine ligand 2 (CCL2), and chemokine ligand 3 (CCL3), although again these were not significantly different. CSF from gram-positive and gram-negative shunt infections had similar levels of interferon gamma (INF-γ), tumor necrosis factor alpha (TNF-α), IL-6, and IL-8. Conclusions This pilot study is the first to characterize the CSF cytokine profile in patients with CSF shunt infection and supports the distinction of chemokine and cytokine profiles between gram-negative and gram-positive infections. Additionally, it demonstrates the potential of CSF chemokines and cytokines as biomarkers for the diagnosis of shunt infection.
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Fiani B, Quadri SA, Farooqui M, D'Apuzzo M, Rosser RJ, Berman BW, Noel J, Xin XS, Badie B, Ramachandran A, Siddiqi J. A brainstem mass of Müllerian type Epithelial Origin without any primary cancer source. J Clin Neurosci 2018; 59:325-332. [PMID: 30337125 DOI: 10.1016/j.jocn.2018.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022]
Abstract
Brainstem tumors are rare, even rarer is a brainstem tumor containing tissues of an embryologic gynecologic origin. We report a very rare case of presence of a calcified heterogeneously contrast enhancing brainstem mass of Müllerian origin in a patient in a 38 year old female with no female genital tract cancer and past surgical history of ventriculoperitoneal (VP) shunt placement for congenital hydrocephalus. To our knowledge this is the very first and unusual case of a mass of gynecologic origin in the brainstem region especially in the setting of no history of gynecological tumor. The authors also reviewed the literature for all tumors reported for anterograde and retrograde dissemination of tumor cells through VP shunt. This case is a reaffirmation of the importance of brain tumor location and tissue diagnosis for the purpose of adjuvant treatment of neurosurgical lesions in the neurocritical care setting. It also highlights the role of catheters as potential routes of iatrogenic transmission not just in anterograde but also in a retrograde manner to the CNS, which is very unusual. This is the only second case to report retrograde flow of tumor cells from an extraneural source up the VP catheters. The authors suggest that intraperitoneal chemotherapy should be considered in the cases of known extraneural abdominal malignancies of high malignant potential with or without the presence of peritoneal infiltration in order to avoid dissemination through VP shunts.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Syed A Quadri
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA.
| | - Mudassir Farooqui
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Massimo D'Apuzzo
- Department of Pathology, City of Hope National Medical Center, Duarte, CA, USA
| | - Robert J Rosser
- Department of Pathology, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Blake W Berman
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jerry Noel
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Xin S Xin
- Division of Neurosurgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Behnam Badie
- Division of Neurosurgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Anirudh Ramachandran
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
| | - Javed Siddiqi
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
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Morosanu CO, Filip GA, Nicolae L, Florian IS. From the heart to the bladder-particularities of ventricular shunt topography and the current status of cerebrospinal fluid diversion sites. Neurosurg Rev 2018; 43:847-860. [PMID: 30338415 DOI: 10.1007/s10143-018-1033-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/28/2018] [Accepted: 09/17/2018] [Indexed: 12/01/2022]
Abstract
Hydrocephalus represents the pathological elevation of cerebrospinal fluid (CSF) levels as a consequence of various embryological or acquired defects. Although the classic method of treatment is by means of diverting the CSF from the ventricular system towards the peritoneum, there are other sites of diversion that have proven their efficiency through time, in the context of complications related to the more common option of intraperitoneal insertion. The aim of the review is to assess and organize a database of all the types of shunt locations from the oldest shunt attempts until present, using Pubmed and Medline and to underline the particularities related to technique, indications, complications and associated epidemiological background. Current literature reveals up to 36 sites of diversion of CSF with a diverse topography varying from cephalic regions such as venous sinuses or mastoid bone, thoracic elements such as the heart or the pleura and abdominopelvic segments such as the peritoneum or the urinary bladder. Several atypical locations were studied such as the fallopian and intestinal shunts. Although ventriculoperitoneal and ventriculoatrial shunts are the most commonly used shunts today, there are some systems such as the ventriculosinusal and ventriculolymphatic shunts that prove to be equally as efficient. The successful treatment of hydrocephalus requires a complete comprehension of the indications and therapeutic options and a reliable evaluation of the risks and possible complications. The profile of cerebral ventricular shunts is highly dynamic and the spectrum of cerebrospinal fluid diversion offers multiple solutions in the benefit of the patient.
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Affiliation(s)
- Cezar Octavian Morosanu
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom.
| | - Gabriela Adriana Filip
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Liviu Nicolae
- Department of Neurosurgery, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Westbury-on-Trym, Bristol, United Kingdom
| | - Ioan Stefan Florian
- Department of Neurosurgery, Cluj County Emergency Hospital, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
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Kanangi SMR, Balasubramaniam C. Shunt infections: a review and analysis of a personal series. Childs Nerv Syst 2018; 34:1915-1924. [PMID: 29978253 DOI: 10.1007/s00381-018-3890-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND PURPOSE CSF diversion shunts are notoriously prone to complications. The most difficult to manage among them is shunt infection, which warrants a prolonged hospital stay. The aim of this paper is to review the pattern of infections, the pathology, and management of shunt infections with special reference to a tertiary pediatric center in a developing country. MATERIALS AND METHODS This is a review of shunt infections in general and a retrospective study of all cases operated in the hospital from 2000 to 2015. RESULTS The authors analyze the data and try to discern patterns, which may enable newer interventions to treat as well as decrease the burden of shunt infections in the future. CONCLUSION It is difficult to determine the true incidence of shunt infections as there is no definition of what constitutes a shunt infection. There are no standardized international guidelines as to how to deal with an infected shunt. Though the ability to treat shunt infection has improved and the incidence of shunt infection has decreased over time, there is still no consensus on the best way to manage it. The prevention is predominantly based on common sense and has helped but a more scientific algorithm is the need of the hour.
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Affiliation(s)
- Santosh Mohan Rao Kanangi
- Department of Pediatric Neurosurgery, Kanchi Kamakoti CHILDS Trust Hospital, 12 A Nageswara Road Nungambakkam, Chennai 34, 600034, India
| | - Chidambaram Balasubramaniam
- Department of Pediatric Neurosurgery, Kanchi Kamakoti CHILDS Trust Hospital, 12 A Nageswara Road Nungambakkam, Chennai 34, 600034, India.
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McKinnon C, Dalton AK. Ventriculoperitoneal shunts. Br J Hosp Med (Lond) 2018; 79:C130-C133. [PMID: 30188215 DOI: 10.12968/hmed.2018.79.9.c130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chris McKinnon
- Post-doctoral Research Fellow, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada, M5T 2S8
| | - Arthur K Dalton
- Skull Base Clinical Fellow, Neurosurgery, Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
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Fadel H, Moon SJ, Klinger NV, Chamiraju P, Eltahawy HA, Moisi MD, Guthikonda M. Candida parapsilosis Infection of Ventriculoperitoneal Shunt in Adult: Case Report and Literature Review. World Neurosurg 2018; 119:290-293. [PMID: 30114539 DOI: 10.1016/j.wneu.2018.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Candida parapsilosis is an incredibly rare cause of ventriculoperitoneal (VP) shunt infections, with only 1 adult case reported in the literature to date. CASE DESCRIPTION We describe the case of a 45-year-old man admitted for a traumatic fall and subsequently treated with VP shunt placement for obstructive hydrocephalus secondary to a cerebellar contusion and intraventricular hemorrhage. Eight months following VP shunt placement, the patient presented with a 2-month history of clear fluid leakage through a dehiscent surgical abdominal wound overlying the distal VP shunt. Cerebrospinal fluid cultures were obtained and grew C. parapsilosis. The patient subsequently underwent VP shunt externalization and began antifungal treatment with intravenous liposomal amphotericin B. Cerebrospinal fluid studies continued to redemonstrate C. parapsilosis infection, for which VP shunt removal and external ventricular drain placement was performed. Three days into treatment with amphotericin B, he endured significant nephrotoxicity necessitating a switch to oral fluconazole. Following 3 weeks of oral fluconazole treatment with negative serial cerebrospinal fluid cultures, the patient underwent external ventricular drain removal and VP shunt insertion. Following the procedure and 22 total days of oral fluconazole treatment, our patient recovered well and was discharged to a rehabilitation facility in stable condition. CONCLUSIONS In our report, we describe the clinical course of our patient and offer a review and analysis of the most up-to-date literature concerning C. parapsilosis shunt infections, as well as treatment guidelines for central nervous system candidiasis.
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Affiliation(s)
- Hassan Fadel
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
| | - Seong-Jin Moon
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
| | - Neil V Klinger
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA.
| | - Parthasarathi Chamiraju
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
| | - Hazem A Eltahawy
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
| | - Marc D Moisi
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
| | - Murali Guthikonda
- Wayne State University School of Medicine, Department of Neurosurgery, Detroit, Michigan, USA
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Craven CL, Thompson SD, Toma AK, Watkins LD. Superficial and Deep Skin Preparation with Povidone-Iodine for Ventriculoperitoneal Shunt Surgery : A Technical Note. J Korean Neurosurg Soc 2018; 62:123-129. [PMID: 30064203 PMCID: PMC6328799 DOI: 10.3340/jkns.2017.0282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/21/2018] [Indexed: 11/30/2022] Open
Abstract
Objective Ventriculoperitoneal (VP) shunt surgery is a common and effective treatment for hydrocephalus and cerebrospinal fluid disorders. Infection remains a major cause of morbidity and mortality after a VP shunt. There is evidence that a deep skin flora microbiome may have a role to play in post-operative infections. In this technical note, we present a skin preparation technique that addresses the issue of the skin flora beyond the initial incision.
Methods The patient is initially prepped, as standard, with. a single layer of 2% CHG+70% isopropyl alcohol. The novel stage is the ‘double incision’ whereby an initial superficial incision receives a further application of povidone-iodine prior to completing the full depth incision.
Results Of the 84 shunts inserted using the double-incision method (September 2015 to September 2016), only one developed a shunt infection.
Conclusion The double incision approach to skin preparation is a unique operative stage in VP shunt surgery that may have a role to play in reducing acute shunt infection.
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Affiliation(s)
- Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Simon D Thompson
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Laurence D Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Akdag O. Management of exposed ventriculoperitoneal shunt on the scalp in pediatric patients. Childs Nerv Syst 2018; 34:1229-1233. [PMID: 29396717 DOI: 10.1007/s00381-017-3702-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The exposure of a ventriculoperitoneal shunt on the scalp is a serious complication. There are limited studies evaluating this complication's management in the literature. The aim of this study is to define the management of shunt salvage and the reconstruction of the scalp. METHODS This retrospective study included seven pediatric patients with ventriculoperitoneal shunts that were exposed on the scalp for various reasons. The demographic characteristics of the patients and the medical and surgical treatments used were recorded. The patient follow-up durations and complications associated with these methods were determined. RESULTS Four female and three male patients with an average age of 5.7 were followed for an average of 9.4 months. All but one of these patients were treated without removing the shunt. While one skin flap was used in one patient, successful repairs were made with double skin flaps in five patients. There were no complications during follow-up for the patients treated with these methods. CONCLUSION In this study, the appropriate management of shunt exposure, which is common in pediatric cases, has been revealed. Given appropriate infection prevention, the reconstruction of the scalp is possible without the removal of the shunt.
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Affiliation(s)
- Osman Akdag
- Department of Plastic Reconstructive and Aesthetic Surgery, Selcuk University, Konya, Turkey.
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Yakut N, Soysal A, Kepenekli Kadayifci E, Dalgic N, Yılmaz Ciftdogan D, Karaaslan A, Akkoc G, Ocal Demir S, Cagan E, Celikboya E, Kanik A, Dagcinar A, Yilmaz A, Ozer F, Camlar M, Turel O, Bakir M. Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study. Br J Neurosurg 2018; 32:196-200. [DOI: 10.1080/02688697.2018.1467373] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
| | - Ahmet Soysal
- Marmara University School of Medicine, Istanbul, Turkey
| | | | - Nazan Dalgic
- Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | | | | | - Gulsen Akkoc
- Marmara University School of Medicine, Istanbul, Turkey
| | | | - Eren Cagan
- Bursa Şevket Yılmaz Training and Research Hospital, Bursa, Turkey
| | - Ezgi Celikboya
- Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ali Kanik
- İzmir Tepecik Training and Research Hospital, Izmir, Turkey
| | | | - Adem Yilmaz
- Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Fusun Ozer
- İzmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Mahmut Camlar
- İzmir Tepecik Training and Research Hospital, Izmir, Turkey
| | - Ozden Turel
- Bezmialem University School Of Medicine, Istanbul, Turkey
| | - Mustafa Bakir
- Marmara University School of Medicine, Istanbul, Turkey
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The role of simultaneous abdominal surgery and wound classification in ventriculoperitoneal shunt complication. Pediatr Surg Int 2017; 33:1221-1230. [PMID: 28965232 DOI: 10.1007/s00383-017-4167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate whether simultaneous abdominal surgery or wound contamination at the time of ventriculoperitoneal (VP) shunt placement are associated with increased shunt complications. METHODS Pediatric patients who underwent VP shunt placement were identified using the National Surgical Quality Improvement Program Pediatric database. VP shunt complication rates were compared between patients who underwent simultaneous abdominal surgeries at the time of VP shunt placement vs those who did not and between those with clean/clean-contaminated and contaminated/dirty wound classifications. Adjusted analysis was performed using 1:5 case-control matching. RESULTS Among 2715 patients who underwent VP shunt placement, 21 had simultaneous abdominal procedures and were matched with 105 control patients. No significant difference was found in overall (34.3 vs 14.3%, p = 0.07), infectious (8.6 vs 4.8%, p = 1.000), or non-infectious (25.7 vs 9.5%, p = 0.156) shunt complications in the simultaneous vs non-simultaneous group, respectively. In a separate analysis of wound classification, 12 patients with contaminated/dirty wounds were matched with 60 patients with clean/clean-contaminated wounds. The rates of shunt infections for clean/clean-contaminated and contaminated/dirty cases were 10.0 and 16.7%, respectively (p = 0.613). CONCLUSION In our matched case-control study, neither simultaneous abdominal surgery nor wound contamination at the time of VP shunt placement demonstrated significant increased risk of 30-day post-operative complication.
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Spirig JM, Frank MN, Regli L, Stieglitz LH. Shunt age-related complications in adult patients with suspected shunt dysfunction. A recommended diagnostic workup. Acta Neurochir (Wien) 2017; 159:1421-1428. [PMID: 28616668 DOI: 10.1007/s00701-017-3237-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/31/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients admitted for suspicion of shunt dysfunction (SD) often show unspecific symptoms and require time-consuming, expensive and even invasive diagnostics involving significant radiation exposure. The purpose of this retrospective study was to analyse the current diagnostic procedures and to propose a process optimisation. METHOD As all patients admitted for suspicion of SD receive imaging studies, we searched for adult patients receiving neuroimaging in the period from January 2010 to July 2013, analysing referring diagnosis, clinical signs, products, diagnostic process and final diagnosis. Recursive partitioning was used to define time intervals for differentiating types of SD. RESULTS A total of 148 patients, aged 18-89 (mean, 54) years, were studied. Forty-two percent were referred by a hospital or rehabilitation centre, 30% by general practitioners and 24% were self-referrals. The admission diagnosis was in the majority "shunt dysfunction" only. Further differentiations were rarely made. An SD was confirmed in 46% of the patients. In 17%, the symptoms were based on another cause and in 37% they could not be clearly attributed to any specific disorder. Abdominal dislocations (2%) and shunt infections (5%) were found within the first 6 months. Over- (3%) and under-drainage (14%) were the most frequent complications during the first 4 years. Disconnections (13%) occurred generally 4 years or more after implantation. Only shunt obstruction (9%) showed no temporal pattern. CONCLUSIONS Symptoms of SD remain mostly unspecific. This study showed that the type of SD depends on the time interval from implantation. We propose a workup strategy for patients with SD based on the temporal profile.
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Affiliation(s)
- José M Spirig
- Department of Neurosurgery, University of Zurich and University Hospital Zurich, 8091, Zurich, Switzerland
| | - Melanie N Frank
- Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University of Zurich and University Hospital Zurich, 8091, Zurich, Switzerland
| | - Lennart H Stieglitz
- Department of Neurosurgery, University of Zurich and University Hospital Zurich, 8091, Zurich, Switzerland.
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Zhang H, Peng J, Hao X, Guo X, Li G. A Simple and Reliable Method for the Diagnosis of Ventriculoperitoneal Shunt Malfunction. World Neurosurg 2017; 103:355-359. [DOI: 10.1016/j.wneu.2017.04.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/05/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
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Ibáñez-Botella G, González-García L, Carrasco-Brenes A, Ros-López B, Arráez-Sánchez MÁ. LOVA: the role of endoscopic third ventriculostomy and a new proposal for diagnostic criteria. Neurosurg Rev 2017; 40:605-611. [DOI: 10.1007/s10143-017-0813-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/19/2016] [Accepted: 01/08/2017] [Indexed: 11/27/2022]
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Habibi Z, Ertiaei A, Nikdad MS, Mirmohseni AS, Afarideh M, Heidari V, Saberi H, Rezaei AS, Nejat F. Predicting ventriculoperitoneal shunt infection in children with hydrocephalus using artificial neural network. Childs Nerv Syst 2016; 32:2143-2151. [PMID: 27638720 DOI: 10.1007/s00381-016-3248-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 09/04/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The relationships between shunt infection and predictive factors have not been previously investigated using Artificial Neural Network (ANN) model. The aim of this study was to develop an ANN model to predict shunt infection in a group of children with shunted hydrocephalus. MATERIALS AND METHODS Among more than 800 ventriculoperitoneal shunt procedures which had been performed between April 2000 and April 2011, 68 patients with shunt infection and 80 controls that fulfilled a set of meticulous inclusion/exclusion criteria were consecutively enrolled. Univariate analysis was performed for a long list of risk factors, and those with p value < 0.2 were used to create ANN and logistic regression (LR) models. RESULTS Five variables including birth weight, age at the first shunting, shunt revision, prematurity, and myelomeningocele were significantly associated with shunt infection via univariate analysis, and two other variables (intraventricular hemorrhage and coincided infections) had a p value of less than 0.2. Using these seven input variables, ANN and LR models predicted shunt infection with an accuracy of 83.1 % (AUC; 91.98 %, 95 % CI) and 55.7 % (AUC; 76.5, 95 % CI), respectively. The contribution of the factors in the predictive performance of ANN in descending order was history of shunt revision, low birth weight (under 2000 g), history of prematurity, the age at the first shunt procedure, history of intraventricular hemorrhage, history of myelomeningocele, and coinfection. CONCLUSION The findings show that artificial neural networks can predict shunt infection with a high level of accuracy in children with shunted hydrocephalus. Also, the contribution of different risk factors in the prediction of shunt infection can be determined using the trained network.
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Affiliation(s)
- Zohreh Habibi
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran
| | - Abolhasan Ertiaei
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Mohammad Sadegh Nikdad
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran
| | - Atefeh Sadat Mirmohseni
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran
| | - Mohsen Afarideh
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran
| | - Vahid Heidari
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran
| | - Hooshang Saberi
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Abdolreza Sheikh Rezaei
- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Farideh Nejat
- Department of Neurosurgery, Children's Hospital Medical Center, Tehran University of Medical Science, Gharib street, Tehran, 141557854, Iran.
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Gutierrez-Murgas YM, Skar G, Ramirez D, Beaver M, Snowden JN. IL-10 plays an important role in the control of inflammation but not in the bacterial burden in S. epidermidis CNS catheter infection. J Neuroinflammation 2016; 13:271. [PMID: 27737696 PMCID: PMC5064787 DOI: 10.1186/s12974-016-0741-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 10/04/2016] [Indexed: 12/15/2022] Open
Abstract
Background Shunt infection is a frequent and serious complication in the surgical treatment in hydrocephalus. Previous studies have shown an attenuated immune response to these biofilm-mediated infections. We proposed that IL-10 reduces the inflammatory response to Staphylococcus epidermidis (S. epidermidis) CNS catheter infection. Methods In this study, a murine model of catheter-associated S. epidermidis biofilm infection in the CNS was generated based on a well-established similar model for S. aureus. The catheters were pre-coated with a clinically derived biofilm-forming strain of S. epidermidis (strain 1457) which were then stereotactically implanted into the lateral left ventricle of 8-week-old C57BL/6 and IL-10 knockout (IL-10 knockout) mice. Bacterial titers as well as cytokine and chemokine levels were measured at days 3, 5, 7, and 10 in mice implanted with sterile and S. epidermidis-coated catheters. Results Cultures demonstrated a catheter-associated and parenchymal infection that persisted through 10 days following infection. Cytokine analysis of the tissue surrounding the catheters revealed greater levels of IL-10, an anti-inflammatory cytokine, in the infected group compared to the sterile. In IL-10 KO mice, we noted no change in bacterial burdens, showing that IL-10 is not needed to control the infection in a CNS catheter infection model. However, IL-10 KO mice had increased levels of pro-inflammatory mediators in the tissues immediately adjacent to the infected catheter, as well as an increase in weight loss. Conclusions Together our results indicate that IL-10 plays a key role in regulating the inflammatory response to CNS catheter infection but not in control of bacterial burdens. Therefore, IL-10 may be a useful therapeutic target for immune modulation in CNS catheter infection but this should be used in conjunction with antibiotic therapy for bacterial eradication.
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Affiliation(s)
| | - Gwenn Skar
- Department of Pediatrics, 985900 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198-5900, USA
| | - Danielle Ramirez
- Pediatric Residency Program, Baylor College of Medicine, San Antonio, TX, 78207, USA
| | - Matthew Beaver
- Department of Pediatrics, 985900 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198-5900, USA
| | - Jessica N Snowden
- Department of Pediatrics, 985900 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198-5900, USA. .,Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
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Bashir A, Sørensen P. Evaluation of intraoperative glove change in prevention of postoperative cerebrospinal fluid shunt infections, and the predictors of shunt infection. Br J Neurosurg 2016; 31:452-458. [PMID: 27626705 DOI: 10.1080/02688697.2016.1229745] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND We have previously suggested that surgical gloves could be a possible means for transferring microorganisms from skin flora to shunt material during surgery. The objectives of this study were to examine (1) whether the rate of shunt infections was reduced after introducing intraoperative glove change before handling the shunt material; (2) clinical presentation of shunt infections, microbiological data, and treatment management; and (3) predictors of shunt infections. METHODS A retrospective study of 432 shunt operations in 295 adults was undertaken over a 7-year period. Study population consisted of two groups: Group A without intraoperative glove change (2003-2006), and Group B with change of the outer pair of the initial double gloves before handling the shunt material (2006-2009). The results were compared at 6- and 12-month postoperatively. A binary logistic regression was performed to determine predictors of shunt infections. RESULTS Overall, 46 (10.6%) infection episodes occurred in 40 (13.6%) patients. Main symptoms were fever, abdominal pain and altered mental status. Propionibacterium acnes was the frequently isolated microorganism, followed by Staphylococcus species. The infection rate was reduced only moderately from 11.8% in Group A to 9.8% in Group B (p = .472). Patients with subarachnoid haemorrhage were more likely to experience shunt infections (17.9%), compared to patients with normal pressure hydrocephalus (5.9%). An increased likelihood of shunt infections for the increased number of subsequent shunt revisions (p = .030) and a trend towards prior history of shunt infections (p = .118) was seen. After adjusting for various covariates, a decreased likelihood of shunt infections for intraoperative glove change was seen at 6-month follow-up for first-time shunt insertion (p = .050). CONCLUSION Intraoperative glove change does not significantly reduce the risk of shunt infection. However, it seems to reduce the infection rate within 6 months in patients undergoing first-time shunt insertion only.
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Affiliation(s)
- Asma Bashir
- a Department of Neurosurgery , University Hospital of Aalborg , Hobrovej , Aalborg , Denmark
| | - Preben Sørensen
- a Department of Neurosurgery , University Hospital of Aalborg , Hobrovej , Aalborg , Denmark
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Ramos TN, Arynchyna AA, Blackburn TE, Barnum SR, Johnston JM. Soluble membrane attack complex is diagnostic for intraventricular shunt infection in children. JCI Insight 2016; 1:e87919. [PMID: 27699221 DOI: 10.1172/jci.insight.87919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Children treated with cerebrospinal fluid (CSF) shunts to manage hydrocephalus frequently develop shunt failure and/or infections, conditions that present with overlapping symptoms. The potential life-threatening nature of shunt infections requires rapid diagnosis; however, traditional microbiology is time consuming, expensive, and potentially unreliable. We set out to identify a biomarker that would identify shunt infection. METHODS CSF was assayed for the soluble membrane attack complex (sMAC) by ELISA in patients with suspected shunt failure or infection. CSF was obtained at the time of initial surgical intervention. Statistical analysis was performed to assess the diagnostic potential of sMAC in pyogenic-infected versus noninfected patients. RESULTS Children with pyogenic shunt infection had significantly increased sMAC levels compared with noninfected patients (3,211 ± 1,111 ng/ml vs. 26 ± 3.8 ng/ml, P = 0.0001). In infected patients undergoing serial CSF draws, sMAC levels were prognostic for both positive and negative clinical outcomes. Children with delayed, broth-only growth of commensal organisms (P. acnes, S. epidermidis, etc.) had the lowest sMAC levels (7.96 ± 1.7 ng/ml), suggesting contamination rather than shunt infection. CONCLUSION Elevated CSF sMAC levels are both sensitive and specific for diagnosing pyogenic shunt infection and may serve as a useful prognostic biomarker during recovery from infection. FUNDING This work was supported in part by the Impact Fund of Children's of Alabama.
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Affiliation(s)
| | - Anastasia A Arynchyna
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama
| | | | - Scott R Barnum
- Department of Microbiology.,Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama
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