Rates and determinants of ventriculostomy-related infections during a hospital transition to use of antibiotic-coated external ventricular drains

Risk Assessment and Recommended Approaches to Optimize Infection Control and Antibiotic Stewardship to Reduce External Ventricular Drain Infection: A Single-Center Study

Background: An external ventricular drain (EVD) is used to release elevated intracranial pressure by draining cerebrospinal fluid (CSF) from the brain's ventricles. The establishment of an EVD is one of the most commonly performed neurosurgical procedures to treat intracranial pressure in patients. Nevertheless, infections are very frequent complications. Identifying the risk factors for EVD-related infections is a key to improving patient safety and outcomes. Methods: We conducted a retrospective, single-center study of patients who underwent EVD implantation between January 2022 and March 2024. Patients were classified into infected and non-infected groups based on their clinical symptoms, as well as laboratory and microbiological results. Patient characteristics and possible risk factors for infection were compared between the two groups. Results: In total, 123 patients treated with 156 EVDs were included in this study, with a mean age of 55.8 (range: 25-84) years. EVD-associated infections were observed in 37 patients (30%). We found no significant association between infection risk and patient characteristics, including gender, primary diagnosis, craniotomy, or immunosuppression. There was no significant difference in terms of EVD insertion, i.e., whether the insertion took place in the operating room (OR) with antibiotic prophylaxis or outside the OR with no periprocedural antibiotic treatment. However, within the intensive care unit (ICU), EVD infection was much lower (13%) if EVD insertion took place in a single-bed room compared to multiple-bed room insertions (34%). Furthermore, there were significant differences in terms of the duration of first EVD (both single and multiple catheterizations) (p < 0.0001) and the total catheterization time (p = 0.0001). Additionally, there was a significant association with patient days in the ICU and EVD catheterization. Conclusions: Revisiting infection control measures is necessary, with special attention to the replacement of EVDs in single-bed ICU rooms, to introduce antibiotic prophylaxis in the ICU. Minimizing unnecessary EVD manipulation during catheterization is crucial in order to decrease the risk of EVD infection.

Risk factors and chlorhexidine dressings in external ventricular drainage: a retrospective analysis on infection rates

This retrospective study endeavors to scrutinize risk factors associated with infections resulting from external ventricular drainage (EVD) and to assess the effectiveness of chlorhexidine dressing in mitigating infection rates. Conducted from January 2018 to July 2023, this single-center study encompassed 108 EVD patients. Comprehensive data on demographics, comorbidities, surgical procedures, and the utilization of chlorhexidine dressing were meticulously compiled. The primary endpoint was the incidence of EVD-associated infections based on CDC criteria. Infection rates attributable to EVD were 24.32% without and 20.59% with chlorhexidine dressing. Notably, diabetes mellitus emerged as the solitary significant infection risk factor (p < 0.01). Although the application of chlorhexidine dressing suggested a propensity for diminishing infection rates, statistical significance remained elusive. No notable disparities were discerned in variables such as catheter type, procedural location, and underlying diseases. Diabetes mellitus has been identified as a significant risk factor for EVD-associated infections. While the utilization of chlorhexidine dressing exhibited a potential reduction in infection rates, the lack of statistical significance underscores the imperative for further research, encompassing more expansive randomized trials, to comprehensively evaluate the safety and efficacy of chlorhexidine dressings in preventing EVD-associated infections.

Risk Factors for External Ventricular Drainage-Related Infection: A Systematic Review and Meta-analysis

Background and Objectives

External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures, but EVD-related infection constitutes a significant health concern. Yet, little consensus identifies the risk factors for the development of EVD-related infection. Therefore, we performed a meta-analysis to systematically summarize existing evidence on the incidence and risk factors for EVD-related infection.

Methods

PubMed, Embase, and the Cochrane Library databases from database inception to February 28, 2022, were searched for all studies investigating the incidence and risk factors for EVD-related infection. Data were assessed by R-4.2.0 software. The meta-analysis was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI).

Results

A total of 48 studies were included. Among the 29 factors analyzed, statistically significant risk factors were subarachnoid hemorrhage(SAH)/intraventricular hemorrhage(IVH) (OR = 1.48, 95% CI = 1.20-1.82, p < 0.001), concomitant systemic infection (OR = 1.90, 95% CI = 1.34-2.70, p < 0.001), other neurosurgical procedures (OR = 1.76, 95% CI = 1.02-3.04, p = 0.041), change of catheter (OR = 5.05, 95% CI = 3.67-6.96, p < 0.001), bilateral EVDs (OR = 2.25, 95% CI = 1.03-4.89, p = 0.041), (cerebrospinal fluid) CSF leak (OR = 3.19, 95% CI = 2.12-4.81, p < 0.001) and duration of EVD >7 days (OR = 4.62, 95% CI = 2.26-9.43, p < 0.001). The use of silver-coated catheters (OR = 0.57, 95% CI = 0.38-0.87, p = 0.008) and antibiotic-impregnated catheters (OR = 0.60, 95% CI = 0.41-0.88, p = 0.009) might help reduce the risk of infection. No significant difference was indicated in studies evaluating factors like diabetes mellitus (OR = 1.25, 95% CI = 0.90-1.75, p = 0.178), steroids used (OR = 1.52, 95% CI = 0.96-2.4, p = 0.074), prophylactic antibiotics(OR = 0.87, 95% CI = 0.66-1.14, p = 0.308).

Discussion

The meta-analysis of various relevant factors in the onset of EVD-related infection in patients submitted to EVD enabled us to establish a more probable profile of the patients who are more likely to develop it during the treatment.

The association between ventriculostomy - Related infection and clinical outcomes: A systematic review and meta-analysis

BACKGROUND

Ventriculostomy - related infection (VRI) is a common complication of patients who require placement of an external ventricular drain (EVD). The clinical outcomes of people who are diagnosed with VRI is poorly characterised. We performed a systematic review and meta-analysis to assess the association between VRI, and clinical outcomes and resource use, in patients treated with an EVD.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of clinical trials to identify clinical trial and cohort studies that reported outcomes including mortality, functional outcome, duration of EVD insertion, and intensive care and hospital length of stay. Inclusion criteria and data extraction were conducted in duplicate. Where sufficient data were available, data synthesis was conducted using a random effects model to provide a pooled estimate of the association between VRI and clinical outcomes and resource use. We also pooled data to provide an estimate of the incidence of VRI in this population.

RESULTS

Nineteen studies including 38,247 patients were included in the meta-analysis. There were twelve different definitions of VRI in the included studies. The pooled estimate of the incidence of VRI was 11 % (95 % confidence interval (CI), 9 % to 14 %). A diagnosis of VRI was not associated with an increase in the estimated odds ratio (OR) for mortality (OR 1.07, 95 % CI 0.59 to 1.92, p = 0.83 I² = 83.5 %), nor was a diagnosis of VRI associated with changes in neurological outcome (OR 1.42, 95 % CI 0.36 to 5.56, p = 0.89, I² = 0.3 %). Those diagnosed with VRI had longer intensive care unit length of stay (estimated pooled mean difference 8.4 days 95 % CI 3.4 to 13.4 days, p = 0.0009, I² = 78.7 %) an increase in hospital length of stay (estimated mean difference 16.4 days. 95 % CI 11.6 to 21.2 days, p < 0.0005, I² = 76.6 %), a prolonged duration of EVD placement (mean difference 5.24 days, 95 % CI 3.05 to 7.43, I² = 78.2 %, p < 0.01), and an increased requirement for an internal ventricular shunt (OR 1.80, 95 % CI 1.32 to 2.46, I² = 8.92 %, p < 0.01).

CONCLUSIONS

Ventriculostomy related infection is not associated with increased mortality or an increased risk of poor neurological outcome, but is associated with prolonged duration of EVD placement, prolonged duration of ICU and hospital admission, and an increased rate of internal ventricular shunt placement.

Prevention of Ventriculostomy Related Infection: Effectiveness of Impregnated Biomaterial

External ventricular drain(EVD) exposes the patient to infectious complications which are associated with significant morbidity and economic burden. Biomaterials impregnated with various antimicrobial agents have been developed to decrease the rate of bacterial colonization and subsequent infection. While promising, antibiotics and silver-impregnated EVD showed conflicting clinical results. The aim of the present review is to discuss the challenges associated with the development of antimicrobial EVD catheters and their effectiveness from the bench to the bedside.

Postprocedural Complications of External Ventricular Drains: A Meta-Analysis Evaluating the Absolute Risk of Hemorrhages, Infections, and Revisions

BACKGROUND

External ventricular drain (EVD) insertion is often a lifesaving procedure frequently used in neurosurgical emergencies. It is routinely done at the bedside in the neurocritical care unit or in the emergency room. However, there are infectious and noninfectious complications associated with this procedure. This meta-analysis sought to evaluate the absolute risk associated with EVD hemorrhages, infections, and revisions. The secondary purpose was to identify and characterize risk factors for EVD complications.

METHODS

We searched the MEDLINE (PubMed) database for "external ventricular drain," "external ventricular drain" + "complications" or "Hemorrhage" or "Infection" or "Revision" irrespective of publication year. Estimates from individual studies were combined using a random effects model, and 95% confidence intervals (CIs) were calculated with maximum likelihood specification. To investigate heterogeneity, the t2 and I2 tests were utilized. To evaluate for publication bias, a funnel plot was developed.

RESULTS

There were 260 total studies screened from our PubMed literature database search, with 176 studies selected for full-text review, and all of these 176 studies were included in the meta-analysis as they met the inclusion criteria. A total of 132,128 EVD insertions were reported, with a total of 130,609 participants having at least one EVD inserted. The pooled absolute risk (risk difference) and percentage of the total variability due to true heterogeneity (I2) for hemorrhagic complication was 1236/10,203 (risk difference: -0.63; 95% CI: -0.66 to -0.60; I2: 97.8%), infectious complication was 7278/125,909 (risk difference: -0.65; 95% CI: -0.67 to -0.64; I2: 99.7%), and EVD revision was 674/4416 (risk difference: -0.58; 95% CI: -0.65 to -0.51; I2: 98.5%). On funnel plot analysis, we had a variety of symmetrical plots, and asymmetrical plots, suggesting no bias in larger studies, and the lack of positive effects/methodological quality in smaller studies.

CONCLUSIONS

In conclusion, these findings provide valuable information regarding the safety of one of the most important and most common neurosurgical procedures, EVD insertion. Implementing best-practice standards is recommended in order to reduce EVD-related complications. There is a need for more in-depth research into the independent risk factors associated with these complications, as well as confirmation of these findings by well-structured prospective studies.

Reduction of ventriculostomy-associated CSF infection with antibiotic-impregnated catheters in pediatric patients: a single-institution study

OBJECTIVE

External ventricular drains (EVDs) are commonly used in the neurosurgical population. However, very few pediatric neurosurgery studies are available regarding EVD-associated infection rates with antibiotic-impregnated EVD catheters. The authors previously published a large pediatric cohort study analyzing nonantibiotic-impregnated EVD catheters and risk factors associated with infections. In this study, they aimed to analyze the EVD-associated infection rate after implementation of antibiotic-impregnated EVD catheters.

METHODS

A retrospective observational cohort of pediatric patients (younger than 18 years of age) who underwent a burr hole for antibiotic-impregnated EVD placement and who were admitted to a quaternary care ICU between January 2011 and January 2019 were reviewed. The ventriculostomy-associated infection rate in patients with antibiotic-impregnated EVD catheters was compared to the authors' historical control of patients with nonantibiotic-impregnated EVD catheters.

RESULTS

Two hundred twenty-nine patients with antibiotic-impregnated EVD catheters were identified. Neurological diagnostic categories included externalization of an existing shunt (externalized shunt) in 34 patients (14.9%); brain tumor (tumor) in 77 patients (33.6%); intracranial hemorrhage (ICH) in 27 patients (11.8%); traumatic brain injury (TBI) in 6 patients (2.6%); and 85 patients (37.1%) were captured in an "other" category. Two of 229 patients (0.9% of all patients) had CSF infections associated with EVD management, totaling an infection rate of 0.99 per 1000 catheter days. This is a significantly lower infection rate than was reported in the authors' previously published analysis of the use of nonantibiotic-impregnated EVD catheters (0.9% vs 6%, p = 0.00128).

CONCLUSIONS

In their large pediatric cohort, the authors demonstrated a significant decline in ventriculostomy-associated CSF infection rate after implementation of antibiotic-impregnated EVD catheters at their institution.

An external ventricular drainage catheter impregnated with rifampicin, trimethoprim and triclosan, with extended activity against MDR Gram-negative bacteria: an in vitro and in vivo study

Background

External ventricular drainage (EVD) carries a high risk of ventriculitis, increasingly caused by MDR Gram-negative bacteria such as Escherichia coli and Acinetobacter baumannii. Existing antimicrobial EVD catheters are not effective against these, and we have developed a catheter with activity against MDR bacteria and demonstrated the safety of the new formulation for use in the brain.

Objectives

Our aim was to determine the ability of a newly formulated impregnated EVD catheters to withstand challenge with MDR Gram-negative bacteria and to obtain information about its safety for use in the CNS.

Methods

Catheters impregnated with three antimicrobials (rifampicin, trimethoprim and triclosan) were challenged in flow conditions at four weekly timepoints with high doses of MDR bacteria, including MRSA and Acinetobacter, and monitored for bacterial colonization. Catheter segments were also inserted intracerebrally into Wistar rats, which were monitored for clinical and behavioural change, and weight loss. Brains were removed after either 1 week or 4 weeks, and examined for evidence of inflammation and toxicity.

Results

Control catheters colonized quickly after the first challenge, while no colonization occurred in the impregnated catheters even after the 4 week challenge. Animals receiving the antimicrobial segments behaved normally and gained weight as expected. Neurohistochemistry revealed only surgical trauma and no evidence of neurotoxicity.

Conclusions

The antimicrobial catheter appears to withstand bacterial challenge for at least 4 weeks, suggesting that it might offer protection against infection with MDR Gram-negative bacteria in patients undergoing EVD. It also appears to be safe for use in the CNS.

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study

OBJECTIVE

Various strategies have been proposed to reduce the incidence of external ventricular drain (EVD)-related infections. The authors retrospectively studied the impact of EVD care management on EVD-related infections at 3 French university hospital intensive care units.

METHODS

Between 2010 and 2014, 462 consecutive adult patients with no evidence of a preexisting CSF infection received EVDs as part of their care at one of the following sites: Grenoble (221 patients), Saint-Etienne (130 patients), and Marseille (111 patients). Written protocols describing the EVD placement procedure, management, and removal were implemented at the 3 sites. Daily CSF sampling and intraventricular administration of antibiotics prior to EVD removal were performed at the Grenoble site only. EVD-related infection was considered for any confirmed ventriculostomy-related infection (VRI) and ventriculitis. VRI was defined as one or more positive CSF cultures or Gram stain with CSF pleocytosis and biochemical abnormalities. Ventriculitis was defined as CSF pleocytosis and biochemical abnormalities with degradation of neurological status and fever.

RESULTS

A total of 6945 EVD days were observed in the entire population. In the Grenoble cohort, the mean cumulative incidence of EVD-related infections was significantly lower than that in the 2 other cohorts: 1.4% (95% CI 0.0%-2.9%) versus 9.2% (95% CI 4.2%-14.2%) and 7.2% (95% CI 2.4%-12.0%) at Saint-Etienne and Marseille, respectively (p < 0.01). Accounting for the duration of external ventricular drainage at each site, the risk for EVD-related CSF infections was significantly higher at Saint-Etienne and Marseille than at Grenoble, with ORs of 15.9 (95% CI 3.6-71.4, p < 0.001) and 10.0 (95% CI 2.2-45.5, p = 0.003), respectively.

CONCLUSIONS

These findings indicate that it is possible to attain a low incidence of EVD-related infections, provided that an EVD care bundle, which can include routine daily CSF sampling, is implemented and strongly adhered to.

Risk Factors of External Ventricular Drain Infection: Proposing a Model for Future Studies

Background: External ventricular drain (EVD) has a major role in the management and monitoring of intracranial pressure (ICP) and its major complication is EVD infection. The risk factors for EVD infection are still a major topic of controversy, hence the need for further research.

Objective: The objective of this review was to identify risk factors that affect the incidence of EVD infection and create a model, which can be used in future studies in order to contribute to elaborations on guideline for EVD.

Methods: A PubMed and Google Scholar literature search was performed and data were extracted from studies published from 1966 through 2017. The search of the databases generated 604 articles and 28 articles of these were found to be relevant. A manual search of the 28 relevant papers generated 4 new articles. Of the 32 relevant articles, 20 articles that performed a multivariate analysis of the suspected risk factors of EVD infection and had a positive culture as a mandatory component in diagnosis were selected for data collection and analysis.

Results: Because reviewed papers investigated only a few influencing factors, and could not determine convincingly the real risk factors of EVD infection and their real strengths. A total of 15 supposed influencing factors which includes: age, age & sex interactions, coinfection, catheter insertion outside the hospital, catheter type, CSF leakage, CSF sampling frequency, diagnosis, duration of catheterization, ICP > 20 mmHg, irrigation, multiple catheter, neurosurgical operation, reduced CSF glucose at catheter insertion and sex were identified.

Conclusion: This review summarizes a set of variables which have to be covered by future clinical epidemiological investigations in order to describe the etiological background of EVD infection.

Improving Ventriculostomy Management: Risk and Cost Reduction Through a Multidisciplinary Approach

OBJECTIVE

Infection is a life-threatening complication of ventriculostomy. The purpose of this quality improvement project was to develop a cost-effective, evidence-based intervention to reduce ventriculostomy-associated infection (VAI) rates.

METHODS

In this retrospective study, patients undergoing ventriculostomy insertion between June 2008 and December 2016 were identified, and charts were reviewed. The study period between June 2008 and August 2010 constituted the baseline (phase 1) in which non-antibiotic-coated ventriculostomy catheters were used and cerebrospinal fluid (CSF) sampling was done daily. Then, 2 sequential interventions were implemented. Between September 2010 and January 2013, antibiotic-coated ventriculostomy catheters (AC-Vs) were used (phase 2). Then, between February 2013 and December 2016, the frequency of CSF sampling was minimized to twice a week (phase 3). The rates of VAI and operational costs, or cost incurred for the external ventricular drain catheter, antibiotics, laboratory analysis, and CSF sampling supplies, were compared for each phase.

RESULTS

The average infection rate for phase 1 was 3.3 infections per 1000 device-days. The VAI rates for phases 2 and 3 were 1.6 and 0.8, respectively. The use of AC-Vs and reduced CSF sampling resulted in a VAI rate decrease of 75.8% (P = 0.01). During 2014, there were no VAIs. The intervention produced an estimated $1.02 million in savings for the institution during phase 3. The average projected savings of this intervention was $175 per patient per day and reduced cost by 72%.

CONCLUSIONS

The use of AC-Vs in combination with decreased frequency of CSF sampling was cost saving and resulted in a significant reduction in device-related infections.

Retrospective Analysis of Ventriculitis in External Ventricular Drains

Background

Nosocomial EVD-related ventriculitis is a major complication and a significant cause of morbidity and mortality in critically ill neurological patients. Questions remain about best management of EVDs. The purpose of this study is to compare our incidence of ventriculitis to studies using different catheters and/or antibiotic coverage schemes and determine whether c-EVD with prolonged antibiotics given for the duration of drain placement is inferior to ac-EVD with pp-abx or ac-EVD with prolonged antibiotics for prevention of ventriculitis.

Methods

A retrospective chart review of all patients who had EVDs placed from January 2010 through December 2015 at home institution was performed. Statistical analysis was performed using Fisher's exact test to compare incidence of ventriculitis identified in other studies with that of home institution.

Results

The study included 107 patients, 66 (61.7%) males and 41 (38.3%) females. Average age was 56 years ranging from 18 to 95 years. Average length of drain placement was 7.8 days ranging from 2 to 23 days. Average length of drain placement in infected drains was 13.3 days ranging from 11 to 15 days. There were 3 cases with positive CSF cultures (Staphylococcus haemolyticus and Staphylococcus epidermidis x 2). There were 2 cases with a CSF having a positive gram stain but failed to yield any bacterial growth on culture and did not meet predefined criteria.

Conclusions

The c-EVD with prolonged antibiotics given for the duration of drain placement is not inferior to ac-EVD with pp-abx or ac-EVD with prolonged antibiotics for prevention of ventriculitis. The c-EVD with prolonged antibiotics is superior to c-EVD with pp-abx and conventional EVD without antibiotics for prevention of ventriculitis. Selection should include considerations for antibiotic stewardship and cost effectiveness. Future studies should also utilize clinical and CSF profile criteria in addition to positive CSF cultures for identifying ventriculitis to prevent line colonization from classification as ventriculitis in analysis.

Will clinical parameters reliably predict external ventricular drain-associated ventriculitis: Is frequent routine cerebrospinal fluid surveillance necessary?

Background:

The placement of an external ventricular drain (EVD) for monitoring and treatment of increased intracranial pressure is not without risk, particularly for the development of associated ventriculitis. The goal of this study was to investigate whether changes in cerebrospinal fluid (CSF), serum, or clinical parameters are correlated with the development of ventriculitis before it occurs, allowing for the determination of optimal timing of CSF collection.

Methods:

An observational retrospective study was conducted between January 2006 and May 2012. A total of 466 patients were identified as having an in-situ EVD placed. Inclusion criteria were age >18 years, glasgow coma scale (GCS) 4-15, and placement of EVD for any indication. Exclusion criteria included recent history of meningitis, cerebral abscess, cranial surgery or open skull fracture within the previous 30 days. A broad definition of ventriculitis was used to separate patients into three initial categories, two of which had sufficient patients to proceed with analysis: suspected ventriculitis and confirmed ventriculitis. CSF sampling was conducted on alternating weekdays.

Results:

A total of 466 patients were identified as having an EVD and 123 patients were included in the final analysis. The incidence of ventriculitis was 8.8%. Only the ratio of glucose CSF: serum <0.5 was found to be of statistical significance, though not correlated to developing a ventriculitis.

Conclusions:

This study demonstrates no reliable tested CSF, serum, or clinical parameters that are effectively correlated with the development of ventriculitis in an EVD patient. Thus, we recommend and will continue to draw CSF samples from patients with in-situ EVDs on our current schedule for as long as the EVD remains in place.

Intracranial Multimodality Monitoring for Delayed Cerebral Ischemia

Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.

Ventriculostomy-related infections: The performance of different definitions for diagnosing infection

INTRODUCTION

Comparison of rates of ventriculostomy-related infections (VRIs) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis.

MATERIALS AND METHODS

We conducted a PubMed search for definitions of VRI using the search strings "ventriculostomy-related infection" and "ventriculostomy-associated infection." We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition.

RESULTS

We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22 to 94% (median 61% with interquartile range (IQR) 56-74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56 to 89% (median: 72%, IQR: 71-78%).

CONCLUSIONS

The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.

Evaluation of a multiplex polymerase chain reaction for early diagnosis of ventriculostomy-related infections

OBJECT

Diagnosis of ventriculostomy-related infections (VRIs) is challenging due to the lack of rapid, sensitive assays for pathogen detection. The authors report the development of a multiplex polymerase chain reaction (PCR) assay for differential diagnosis of common VRI pathogens.

METHODS

MassTag PCR was used to develop a multiplex assay for detection of 11 VRI pathogens. The assay was established and optimized using cloned template standards and spiked samples and was then evaluated on CSF specimens from ventricular drains. Subjects were grouped into definite VRI, possible VRI, or no VRI based on conventional microbiology, CSF evaluation, and clinical parameters.

RESULTS

CSF specimens were obtained from 45 subjects (median age 49 years, interquartile range 32-63 years; 51% were male). The assay detected 10-100 genome copies. It detected a pathogen in 100% (6 of 6) of definite VRI cases in which a pathogen targeted by the assay was present; these represented 67% of all definite VRIs (6 of 9). Among subjects with a possible VRI, the assay detected a pathogen in 29% (5 of 17). In subjects without overt infection the presence of a pathogen was detected in 32% of subjects (6 of 19), albeit with lower signal compared with the VRI group.

CONCLUSIONS

MassTag PCR enabled parallel testing of CSF specimens for 11 pathogens of VRI. The high sensitivity of PCR combined with possible device colonization, specimen contamination, and concurrent antibiotic treatments limit the clinical value of the assay, similar to other current diagnostic approaches. With further optimization, multiplex PCR may provide timely identification of multiple possible VRI pathogens and guide management, complementing classic culture approaches.

No additional protection against ventriculitis with prolonged systemic antibiotic prophylaxis for patients treated with antibiotic-coated external ventricular drains

OBJECT External ventricular drains (EVDs) are commonly used for CSF diversion but pose a risk of ventriculitis, with rates varying in frequency from 2% to 45%. Results of studies examining the utility of prolonged systemic antibiotic therapy for the prevention of EVD-related infection have been contradictory, and no study to date has examined whether this approach confers additional benefit in preventing ventriculitis when used in conjunction with antibiotic-coated EVDs (ac-EVDs). METHODS A prospective performance analysis was conducted over 4 years to examine the impact of discontinuing systemic antibiotic prophylaxis after insertion of an ac-EVD on rates of catheter-related ventriculitis. Ventriculitis and other nosocomial infections were ascertained by a qualified infection disease nurse using definitions based on published standards from the Centers for Disease Control and Prevention, comparing the period when patients received systemic antibiotic therapy for the duration of EVD treatment (Period 1) compared with only for the peri-insertion period (Period 2). Costs were analyzed and compared across the 2 time periods. RESULTS Over the 4-year study period, 866 patients were treated with ac-EVDs for a total of 7016 catheter days. There were 8 cases of ventriculitis, for an overall incidence of 0.92%. Rates of ventriculitis did not differ significantly between Period 1 and Period 2 (1.1% vs 0.4%, p = 0.22). The rate of nosocomial infections, however, was significantly higher in Period 1 (2.0% vs 0.0% in Period 2, p = 0.026). Cost savings of $162,516 were realized in Period 2 due to decreased drug costs and savings associated with the reduction in nosocomial infections. CONCLUSIONS Prolonged systemic antibiotic therapy following placement of ac-EVDs does not seem to reduce the incidence of catheter-related ventriculitis and was associated with a higher rate of nosocomial infections and increased cost.

Antimicrobial-impregnated and -coated shunt catheters for prevention of infections in patients with hydrocephalus: a systematic review and meta-analysis

OBJECT The aim of this study was to evaluate the effectiveness of antimicrobial-impregnated and -coated shunt catheters (antimicrobial catheters) in reducing the risk of infection in patients undergoing CSF shunting or ventricular drainage. METHODS The PubMed and Scopus databases were searched. Catheter implantation was classified as either shunting (mainly ventriculoperitoneal shunting) or ventricular drainage (mainly external [EVD]). Studies evaluating antibioticimpregnated catheters (AICs), silver-coated catheters (SCCs), and hydrogel-coated catheters (HCCs) were included. A random effects model meta-analysis was performed. RESULTS Thirty-six studies (7 randomized and 29 nonrandomized, 16,796 procedures) were included. The majority of data derive from studies on the effectiveness of AICs, followed by studies on the effectiveness of SCCs. Statistical heterogeneity was observed in several analyses. Antimicrobial shunt catheters (AICs, SCCs) were associated with lower risk for CSF catheter-associated infections than conventional catheters (CCs) (RR 0.44, 95% CI 0.35-0.56). Fewer infections developed in the patients treated with antimicrobial catheters regardless of randomization, number of participating centers, funding, shunting or ventricular drainage, definition of infections, de novo implantation, and rate of infections in the study. There was no difference regarding gram-positive bacteria, all staphylococci, coagulase-negative streptococci, and Staphylococcus aureus, when analyzed separately. On the contrary, the risk for methicillin-resistant S. aureus (MRSA, RR 2.64, 95% CI 1.26-5.51), nonstaphylococcal (RR 1.75, 95% CI 1.22-2.52), and gram-negative bacterial (RR 2.13, 95% CI 1.33-3.43) infections increased with antimicrobial shunt catheters. CONCLUSIONS Based on data mainly from nonrandomized studies, AICs and SCCs reduce the risk for infection in patients undergoing CSF shunting. Future studies should evaluate the higher risk for MRSA and gram-negative infections. Additional trials are needed to investigate the comparative effectiveness of the different types of antimicrobial catheters.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Ventricular access device infection rate: a retrospective study and review of the literature

PURPOSE

Ventricular access devices (VAD) are often used for treatment of posthemorrhagic hydrocephalus (PHH) in preterm infants. The reported rates of infection have varied and range from 0 to 22 %. The objective of our study is to present our VAD associated infection at our institution.

METHODS

The charts for patients that had VADs inserted between May 1, 2009 and October 31, 2013 at a single institution (Children's Healthcare of Atlanta) were retrospectively reviewed. The number of VAD infections, defined as either cerebrospinal fluid (CSF)-positive cultures or wound complication, was recorded. Of patients that survived, the number of VAD to shunt conversions was also examined. The data from 15 previously published studies were pooled to determine overall VAD infection and VAD to shunt conversion rates.

RESULTS

A total of 142 VADs were placed. There were 13 infections (9.2 %), 11 of which had CSF-positive cultures (7.7 %). There were two wound complications with negative CSF cultures. Six patients died after VAD placement for reasons unrelated to their VAD surgeries (4.2 %). In the remaining patients, there were 113 VAD to shunt conversions (83.1 %). Fifteen studies that reported VAD infections were analyzed; an overall infection rate of 7.0 % and VAD to shunt conversion rate of 79 % were calculated.

CONCLUSIONS

While VAD is a valuable tool to treat PHH, it remains a procedure with an infection rate between 7.0 and 8.0 %. Close follow-up is needed to capture these adverse events as early as possible. Approximately 80 % of patients with PHH will require permanent CSF diversion.

Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains

PURPOSE

The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatric population.

METHODS

In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series.

RESULTS

One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 0-15.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17 %) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infection rate was 3.8 % (5/133). The mean duration of insertion was 10 days (range 0-42 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone. There was a significant difference (p < 0.05) when comparing our infection rate to 14 publications of infection rates in short-tunnelled EVDs; however, there was no difference when comparing our data to three publications using LTEVDs.

CONCLUSION

The use of an antibiotic-impregnated LTEVD, managed according to a predefined guideline, is associated with significantly reduced infection and displacement rates when compared with contemporary series. It is suggested that this reduction is of both clinical and economic benefits.