Prophylactic methicillin for shunt operations: effects on incidence of shunt malfunction and infection

Route of antibiotic prophylaxis for prevention of cerebrospinal fluid-shunt infection

BACKGROUND

The main complication of cerebrospinal fluid (CSF) shunt surgery is shunt infection. Prevention of these shunt infections consists of the perioperative use of antibiotics that can be administered in five different ways: orally; intravenously; intrathecally; topically; and via the implantation of antibiotic-impregnated shunt catheters.

OBJECTIVES

To determine the effect of different routes of antibiotic prophylaxis (i.e. oral, intravenous, intrathecal, topical and via antibiotic-impregnated shunt catheters) on CSF-shunt infections in persons treated for hydrocephalus using internalised CSF shunts.

SEARCH METHODS

We conducted a systematic electronic search without restrictions on language, date or publication type. We performed the search on the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase, with the help of the Information Specialist of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. The search was performed in January 2018.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials that studied the effect of antibiotic prophylaxis, in any dose or administration route, for the prevention of CSF-shunt infection in patients that were treated with an internal cerebrospinal fluid shunt. Patients with external shunts were not eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included studies. We resolved disagreements by discussion or by referral to an independent researcher within our department when necessary. Analyses were also performed by at least two authors.

MAIN RESULTS

We included a total of 11 small randomised controlled trials, containing 1109 participants, in this systematic review. Three of these studies included solely children, and the remaining eight included participants of all ages. Most studies were limited to the evaluation of ventriculoperitoneal shunts. However, five studies included participants with ventriculoatrial shunts, of which one study contained four participants with a subduroperitoneal shunt. We judged four out of 11 (36%) trials at unclear risk of bias, while the remaining seven trials (64%) scored high risk of bias in one or more of the components assessed.We analysed all included studies in order to estimate the effect of antibiotic prophylaxis on the proportion of shunt infections regardless of administration route. Although the quality of evidence in these studies was low, there may be a positive effect of antibiotic prophylaxis on the number of participants who had shunt infections (RR 0.55, 95% CI 0.36 to 0.84), meaning a 55% reduction in the number of participants who had shunt infection compared with standard care or placebo.Within the different administration routes, only within intravenous administration of antibiotic prophylaxis there may be evidence of an effect on the risk of shunt infections (RR 0.55, 95% CI 0.33 to 0.90). However, this was the only route that contained more than two studies (8 studies; 797 participants). Evidence was uncertain for both, intrathecal administration of antibiotics (RR 0.73, 95% CI 0.28 to 1.93, 2 studies; 797 participants; low quality evidence) and antibiotic impregnated catheters (RR 0.36, 95% CI 0.10 to 1.24, 1 study; 110 participants; very low quality evidence) AUTHORS' CONCLUSIONS: Antibiotic prophylaxis may have a positive effect on lowering the number of participants who had shunt infections. However, the quality of included studies was low and the effect is not consistent within the different routes of administration that have been analysed. It is therefore uncertain whether prevention of shunt infection varies by different antibiotic agents, different administration routes, timing and doses; or by characteristics of patients, e.g. children and adults. The results of the review should be seen as hypothesis-generating rather than definitive, and the results should be confirmed in adequately powered trials or large multicentre studies in order to obtain high-quality evidence in the field of ventricular shunt infection prevention.

Antibiotic prophylaxis for shunt surgery of children: a systematic review

OBJECTIVE

The object of this study was to evaluate the clinical effectiveness of antibiotic prophylaxis in children who underwent placement of intracranial ventricular shunts.

METHODS

In this paper, the authors report a systematic review and meta-analysis of infection rate for pediatric shunt implantation surgery. Randomized or non-randomized controlled trials for comparing the use of prophylactic antibiotics in intracranial ventricular shunt procedures with placebo or no antibiotics were included in the review.

RESULTS

Seven published reports of eligible studies involving 694 participants meet the inclusion criteria. Compared with the control group, antibiotic prophylaxis had made a significant difference in infection rate (RR = 0.59, 95% CI = 0.38, 0.90, P < 0.05).

CONCLUSION

Although current evidence demonstrates that antibiotic prophylaxis can lead to a significant reduction of the infection rate of shunt surgery, more evidence from advanced multi-center studies is needed to provide instruction for the use of prophylactic antibiotics.

Analysis of the potential risk of central intravenous lines and/or total parenteral nutrition with ventriculoatrial shunts

OBJECT

The distal catheter of a ventriculoatrial (VA) cerebrospinal fluid shunt is potentially exposed to bacterial seeding from a subclavian central line. The risk of blood stream infections (BSIs) from central lines increases with administration of total parenteral nutrition (TPN). The potential risks of shunt malfunction or infection in patients with a VA shunt and a concurrent subclavian central line and/or TPN administration have not been studied.

METHODS

A retrospective review of 49 pediatric patients with placement of a VA shunt was performed. Three outcome measures were studied: shunt malfunction, shunt infection, and bacteremia/fungemia requiring shunt removal. All outcomes were measured by 1 year after shunt insertion. We analyzed the following potential risk factors: age at shunt insertion, prior ventriculoperitoneal (VP) shunt, prior shunt infection, abdominal infection/necrotizing enterocolitis (NEC), concurrent subclavian central line, and administration of TPN. The association between each risk factor and outcome was evaluated using Fisher's exact test to generate the relative risk. Additionally, a logistic regression analysis was performed to evaluate the odds ratio of the outcomes to risk factors considering age as a covariate.

RESULTS

The average age at shunt insertion was 6.3 ± 7.6 years. The most common diagnosis was posthemorrhagic hydrocephalus of prematurity (53.1 %). Fifteen patients (30.1 %) had a shunt malfunction within 1 year, 6 (12.2 %) had a shunt infection, and 3 (6.1 %) required removal of the shunt due to bacteremia/fungemia. The age at shunt insertion was not a statistically significant independent risk factor for any of the three outcomes. Prior shunt infection predicted an increased risk for both future shunt malfunction and infection in both the associative relative risk analysis and the age-dependent logistic regression analysis, although the correlation did not reach statistical significance. The presence of a subclavian central line or TPN administration did not statistically increase the risk over baseline for any of the outcomes in either analysis.

CONCLUSIONS

The relatively small number of patients limits the power of the study. Considering this limitation, the data suggests that the presence of a concurrent subclavian central line or administration of TPN does not increase the risk of shunt malfunction or infection over the baseline of this high-risk cohort.

Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts

BACKGROUND

Systemic antibiotics and antibiotic-impregnated shunt systems are often used to prevent shunt infection.

OBJECTIVES

To evaluate the effectiveness of either prophylactic systemic antibiotics or antibiotic-impregnated shunt systems for preventing infection in patients who underwent surgical introduction of intracranial ventricular shunts.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and the meeting proceedings from the American Association of Neurological Surgeons and from the European Association of Neurosurgical Societies, until June 2005.

SELECTION CRITERIA

We included randomized or quasi-randomized controlled trials comparing the use of prophylactic antibiotics (either systemic or antibiotic-impregnated shunt systems) in intracranial ventricular shunt procedures with placebo or no antibiotics.

DATA COLLECTION AND ANALYSIS

Two authors appraised quality and extracted data independently.

MAIN RESULTS

We included seventeen trials with overall 2134 participants. We performed two separate meta-analyses: one that evaluated the use of systemic prophylactic antibiotics and another that evaluated the use of antibiotic-impregnated systems. All studies included shunt infection in their primary outcome. We could not analyse all-cause mortality regarding systemic antibiotics due to lack of data. No significant differences were found (odds ratio (OR): 1.47, 95% confidence intervals (CI) 0.83 to 2.62) for this outcome regarding the use of antibiotic-impregnated catheters compared with standard ones. The use of systemic antibiotic prophylaxis and the use of antibiotic-impregnated catheters were associated with a decrease in shunt infection (OR: 0.52, 95% CI 0.36 to 0.74 and OR: 0.21, 95% CI 0.08 to 0.55 respectively). We found no significant benefit for shunt revision in both meta-analyses that evaluated systemic antibiotics and impregnated-shunt systems. We found no significant differences between the subgroups evaluated: type of shunt (internal/external, ventriculoperitoneal/ventriculoatrial), age and duration of the administration of antibiotics.

AUTHORS' CONCLUSIONS

We could demonstrate a benefit of systemic prophylactic antibiotics for the first 24 hours postoperatively to prevent shunt infection, regardless of the patient's age and the type of internal shunt used. The benefit of its use after this period remains uncertain. However this data derives from the rate of shunt infection, which is an intermediary outcome. Future trials should evaluate the effectiveness of different regimens of systemic antibiotics rather than placebo, and should include all-cause mortality, shunt revision and adverse events as additional outcomes. Evidence suggests that antibiotic-impregnated catheters reduce the incidence of shunt infection although more well-designed clinical trials testing the effect of antibiotic-impregnated shunts are required to confirm their net benefit.

Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts

Postoperative infections are major complications of cerebrospinal fluid (CSF) shunting in the treatment of hydrocephalus and other conditions with obstructed CSF circulation. In a retrospective study 884 first-time shunted patients with hydrocephalus operated on in the years 1958-1989 were investigated with special reference to the infection rate and to the influence of the following variables: time period, age of the patient, education of the neurosurgeon, length and time of the operation and the exact placement of the distal drain. The overall infection rate for all implanted CSF shunts was 7.4% (5.7-9.3%) and the acute rate of infection was 6.2% (4.6-7.9%). The rate of infection was virtually constant for all variables with the exception of the education of the neurosurgeon. Neurosurgical trainees particularly had a significantly higher rate of infection. Shunt infection is still a major complication. The infection rate has not declined in recent decades. It is not possible to relate any main cause to the infection rate. The literature recommends removal of the infected shunt combined with antibiotics. The use of prophylactic antibiotics is still controversial. No prospective, double-blind studies, including a sufficiently large number of patients to evaluate this issue, exist today.

A long-term complication of burying a shunt valve in the skull

One of the most common causes of shunt malfunction is infection; a major contributing factor to this infection in neonates is scalp necrosis over the valve site. One of the methods recommended to avoid this requires the burying of the valve in the skull bone. We present a case of a long-term complication from this procedure: the shunt slowly disconnected, over a prolonged period, leading to the formation of the fibrous tunnel which enabled the shunt to function intermittently. We recommend that the practice of burying the shunt into the skull bone is be reconsidered.

An attempt to prevent the problem of shunt-tube migration

Five children are presented with complications related to migration of peritoneal shunt tubes. Anchoring the distal end of the peritoneal tube to the peritoneum was found to be a satisfactory answer to the problem in 13 children. This simple method does not add much to the operation time and has prevented shunt-tube migration in the group studied.

Cerebrospinal fluid shunt infections in children. A study on the relationship between the etiology of hydrocephalus, age at the time of shunt placement, and infection rate

A total of 431 patients who underwent their first cerebrospinal fluid shunt insertion at Children's Memorial Hospital over a 10-year period were retrospectively studied with regard to the relationship between the etiology of the hydrocephalus, age at the time of shunt placement, and infection rate. Forty percent of the patients had constrictive hydrocephalus and meningomyelocele, 33% congenital communicating or obstructive hydrocephalus, and 18% tumors. Intraventricular hemorrhage and meningitis accounted for the remaining 8%. Eighty-three percent of the patients were less than 1 year old at the time of surgery; 18% were 1 week old or younger. A total of 1,485 procedures were performed with an average of 3 procedures per patient. Ninety-six patients had infections, resulting in a 22% infection rate per patient and a 6% infection rate per procedure. No significant correlation was evident between etiology of the hydrocephalus and infection rate (P greater than 0.05), even though meningomyelocele patients seemed to be more prone to infection than congenital hydrocephalus patients (P = 0.06). Age at the time of shunt placement was related to infection rate, with younger patients having more infections than older ones (P less than 0.01). More in-depth analysis of the relationship between age and infection rate was possible in the meningomyelocele and congenital hydrocephalus groups, owing to the significant number of these patients that fell into each one of the subdivisions chosen with respect to age at the time of shunt placement. Meningomyelocele patients shunted in the first week of life have a higher infection rate than those shunted at 2 weeks of age or older (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Malfunctioning ventriculoperitoneal shunts. Clinical and pathological features

The authors report the clinical and pathological findings in 201 procedures to revise malfunctioning ventriculoperitoneal shunts in 114 patients. The revised shunts were predominantly Raimondi three-piece systems. Collection of fluid along the shunt track is emphasized as an early clinical feature of shunt malfunction. In some cases, there are few clinical signs of shunt infection, and the first indication of it may be shunt malfunction. Ventricular catheter obstruction was caused by tissue from the region in addition to choroid plexus. Inflammation was frequently found around both ventricular and peritoneal catheters. Foreign bodies (cotton fiber, hair, and talc) and granulomatous inflammation were often present at both ends. Tissues obstructing the peritoneal catheter included embolic neoplastic cells, choroid plexus, and leptomeninges. There was also more necrotic debris at the peritoneal end. To prevent shunt malfunction, attention should be directed to: 1) optimal placement of ventricular catheters inside the lateral ventricle; 2) prevention of infection; 3) avoidance of contamination by cotton fibers, hair, or talc; and 4) improvements in the biocompatibility of the implanted materials.