Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection

Techniques to Reduce the Rate of Infection in Surgeries for Cerebrospinal Fluid Shunting in Adults

OBJECTIVE

Cerebrospinal fluid shunt placement is associated with high rates of infection. Multiple standardized protocols, particularly in pediatric populations, have been proposed to mitigate this infection rate. We sought to determine the effectiveness of a standardized shunt infection protocol in a large adult population.

METHODS

A retrospective cohort study of adults presenting for primary cerebrospinal fluid shunt placement from 2012 to 2022. The primary outcome of interest was shunt infection. The primary exposure of interest was implementation of the shunt protocol (began October 2015). Secondary exposures of interest included use and type of perioperative antibiotics and total operating room time.

RESULTS

In total, 820 patients were included, 140 before protocol implementation and 680 after protocol implementation. The overall number of infections over the study period was 15 (1.8% infection rate), with 8 infections preprotocol (5.7%) and 7 infections during the protocol period (1.0%). The infection protocol was associated with a decreased infection rate (odds rato [OR] 0.18, 95% confidence interval [CI] 0.05-0.58, P = 0.002). Total operating room time (OR 1.38 per 30-minute increase, 95% CI 1.05-1.81, P = 0.021) was associated with increased infection rate. Patients who received antibiotics with primarily gram-positive coverage (cefazolin or equivalent) did not have significantly different odds of shunt infection as patients who received broad-spectrum coverage (OR 2.10, 95% CI 0.56-7.88, P = 0.274).

CONCLUSIONS

The implementation of an evidence-based perioperative shunt infection protocol is an effective method to decrease shunt infections. Broad-spectrum perioperative antibiotics may not have greater efficacy than gram-positive only coverage, but more research is required.

Reducing ventriculoperitoneal shunt infection with intraoperative glove removal

BACKGROUND

Contamination of ventriculoperitoneal shunts (VPS) by cutaneous flora, particularly coagulase-negative staphylococci, is a common cause of shunt infection and failure, leading to prolonged hospital stay, higher costs of care, and poor outcomes. Glove contamination may occur during VPS insertion, increasing risk of such infections.

METHODS

We performed a systematic search of the PubMed database for studies published January 1, 1970, through August 31, 2021 that documented VPS infection rates before and after implementing a practice of double gloving with change or removal of the outer glove immediately prior to shunt insertion.

RESULTS

Among 272 reports screened, 4 were eligible for review based on our inclusion criteria. The incidence of VPS infection was reduced in all 4 quasi-experimental studies with an aggregate incidence of VPS infection of 11.8% before the change in intraoperative protocol and 4.9% after protocol change. One study documented reduced hospital stay with this change in protocol.

CONCLUSION

The risk of VPS infection is reduced by removal or replacement of the outer surgical gloves immediately prior to intraoperative insertion of a VPS as part of an infection control bundle.

Clinical Characteristics and Treatment of Early and Delayed Intra-Ccranial Infection After Ventriculoperitoneal Shunt in Adults: Retrospective Analysis of Nineteen Cases

Objectives: Intra-cranial infection is the most serious complication after ventriculoperitoneal shunt (VPS). There were differences in clinical characteristics between early (occurs within one month after VPS, the early group) and delayed (occurs 1 month or more after VPS, the delayed group) infections. The aim of this study is to clarify the differences between the two groups. Patients and Methods: All cases diagnosed as intracranial infection after VPS between September 2017 and December 2021 were collected. Clinical data were reviewed and analyzed retrospectively. Results: Nineteen cases met the inclusion criteria, including 12 cases in the early group and seven cases in the delayed group. There were no significant differences between the two groups in gender, age, and etiology of hydrocephalus. Cases in the early group usually had fever with worsening consciousness (11; 91.7%), which was caused by surgical operations (10; 83.3%) with gram-positive coccis infection (9; 75.0%), whereas those in the delayed group had abdominal pain (5; 71.4%), caused by abdominal factor (7; 100%) with gram-negative bacilli infection (6; 85.7%). There were differences in symptoms (p < 0.01), causes of infection (p < 0.001), and pathogens (p < 0.05). Shunt removal was performed for all 19 cases. After the infection was controlled, eight cases received VPS again, and no re-infection occurred after a follow-up of four to 22 months. Conclusions: It is suggested in this study that there were differences between the two groups in terms of etiology, symptoms, and pathogens. The results can provide theoretical basis for prevention, early diagnosis, and reasonable treatment of infection after VPS.

A Proposed Protective Protocol Predicting Reduction of Shunt Infection

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.

Preventive infection control in cardiac device implantation

BACKGROUND

Cardiac implantable electronic devices have been increasingly used in recent years; as a result, there has been a rise in device-related complications. Pacemaker-associated infection is challenging to manage, including system removal, antimicrobial therapy and reimplantation at another site. The aim of this study was to evaluate adherence to the steps in an infection control protocol in cardiac device implantation.

RESULTS

A total of 100 patients referred for cardiac device implantation were enrolled in the study. They were evaluated with regard to the application of infection control measures during device implantation and followed-up for 6 months to detect clinical signs of device-related infection (DRI). A significant correlation was found between the development of postoperative DRI and the presence or absence of the following factors: increasing patient age (p = 0.010), diabetes mellitus (p = 0.024), number of operators ≥4 (p = 0.001), implantation of a biventricular system (p = 0.025), duration of sterilization (p = 0.001), wearing double gloves (p < 0.001) and postoperative hematoma (p = 0.021).

CONCLUSIONS

The study identified the following risk factors for DRI: age, diabetes mellitus and cardiac resynchronization therapy system implantation (p = 0.025). Antiseptic measures such as double-glove technique and duration of skin disinfection prior to the procedure, as well as environmental factors, also influenced device infection, as did the number of operators/staff and pocket hematoma.

[Placement of ventricle peritoneal shunt in the adult patient. A new protocol]

Introducción:

La colocación de un shunt ventrículo-peritoneal, a pesar de considerarse un procedimiento de baja complejidad, puede devenir en una serie de complicaciones. Nuestro equipo quirúrgico desarrolló e implementó a partir de junio de 2016 un nuevo protocolo. El objetivo del presente trabajo es: describir e ilustrar paso a paso la técnica quirúrgica utilizada y demostrar que el uso del “nuevo protocolo” disminuye significativamente las complicaciones asociadas al procedimiento.

Material y métodos:

Desde junio de 2014 a noviembre de 2017 se intervinieron 184 pacientes en relación a sistemas de derivación de LCR. Se realizó un estudio retrospectivo que incluyó los pacientes con colocación primaria de shunt ventrículo-peritoneal (n=114). El seguimiento promedio fue de 14,2 meses (rango 6-38). Para el análisis estadístico se dividió a la muestra en 2 grupos: “protocolo previo” (n=59) y “nuevo protocolo” (n=55). Para describir la técnica quirúrgica se utilizó el archivo fotográfico y los partes quirúrgicos.

Resultados:

Se describió la técnica quirúrgica en 7 fases. La cantidad de pacientes con alguna complicación fue significativamente menor luego de implementar el “nuevo protocolo” (20% versus 39% respectivamente; p=0,04). En el grupo “nuevo protocolo” no se registró infección alguna asociada a shunt.

Conclusión:

Se presentó e ilustró, de manera clara y detallada, la técnica de colocación de shunt ventrículo-peritoneal en 7 fases. Esta técnica, junto a una serie de normas, constituyen un “nuevo protocolo”. La aplicación de éste disminuyó significativamente las complicaciones asociadas al procedimiento. La tasa de infección “cero” no es una utopía.

Evaluation of an in vivo model for ventricular shunt infection: a pilot study using a novel antimicrobial-loaded polymer

OBJECTIVE

Ventricular shunt infection remains an issue leading to high patient morbidity and cost, warranting further investigation. The authors sought to create an animal model of shunt infection that could be used to evaluate possible catheter modifications and innovations.

METHODS

Three dogs underwent bilateral ventricular catheter implantation and inoculation with methicillin-sensitive Staphylococcus aureus (S. aureus). In 2 experimental animals, the catheters were modified with a polymer containing chemical "pockets" loaded with vancomycin. In 1 control animal, the catheters were polymer coated but without antibiotics. Animals were monitored for 9 to 11 days, after which the shunts were explanted. MRI was performed after shunt implantation and prior to catheter harvest. The catheters were sonicated prior to microbiological culture and also evaluated by electron microscopy. The animals' brains were evaluated for histopathology.

RESULTS

All animals underwent successful catheter implantation. The animals developed superficial wound infections, but no neurological deficits. Imaging demonstrated ventriculitis and cerebral edema. Harvested catheters from the control animal demonstrated > 104 colony-forming units (CFUs) of S. aureus. In the first experimental animal, one shunt demonstrated > 104 CFUs of S. aureus, but the other demonstrated no growth. In the second experimental animal, one catheter demonstrated no growth, and the other grew trace S. aureus. Brain histopathology revealed acute inflammation and ventriculitis in all animals, which was more severe in the control.

CONCLUSIONS

The authors evaluated an animal model of ventricular shunting and reliably induced features of shunt infection that could be microbiologically quantified. With this model, investigation of pathophysiological and imaging correlates of infection and potentially beneficial shunt catheter modifications is possible.

Shunt infections: a review and analysis of a personal series

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.

Risk factors for surgical site infection following nonshunt pediatric neurosurgery: a review of 9296 procedures from a national database and comparison with a single-center experience

OBJECTIVE Surgical site infection (SSI) following CSF shunt operations has been well studied, yet risk factors for nonshunt pediatric neurosurgery are less well understood. The purpose of this study was to determine SSI rates and risk factors following nonshunt pediatric neurosurgery using a nationwide patient cohort and an institutional data set specifically for better understanding SSI. METHODS The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) database for the years 2012-2014, including all neurosurgical procedures performed on pediatric patients except CSF shunts and hematoma evacuations. SSI included deep (intracranial abscesses, meningitis, osteomyelitis, and ventriculitis) and superficial wound infections. The authors performed univariate analyses of SSI association with procedure, demographic, comorbidity, operative, and hospital variables, with subsequent multivariate logistic regression analysis to determine independent risk factors for SSI within 30 days of the index procedure. A similar analysis was performed using a detailed institutional infection database from Children's of Alabama (COA). RESULTS A total of 9296 nonshunt procedures were identified in NSQIP-P with an overall 30-day SSI rate of 2.7%. The 30-day SSI rate in the COA institutional database was similar (3.3% of 1103 procedures, p = 0.325). Postoperative time to SSI in NSQIP-P and COA was 14.6 ± 6.8 days and 14.8 ± 7.3 days, respectively (mean ± SD). Myelomeningocele (4.3% in NSQIP-P, 6.3% in COA), spine (3.5%, 4.9%), and epilepsy (3.4%, 3.1%) procedure categories had the highest SSI rates by procedure category in both NSQIP-P and COA. Independent SSI risk factors in NSQIP-P included postoperative pneumonia (OR 4.761, 95% CI 1.269-17.857, p = 0.021), immune disease/immunosuppressant use (OR 3.671, 95% CI 1.371-9.827, p = 0.010), cerebral palsy (OR 2.835, 95% CI 1.463-5.494, p = 0.002), emergency operation (OR 1.843, 95% CI 1.011-3.360, p = 0.046), spine procedures (OR 1.673, 95% CI 1.036-2.702, p = 0.035), acquired CNS abnormality (OR 1.620, 95% CI 1.085-2.420, p = 0.018), and female sex (OR 1.475, 95% CI 1.062-2.049, p = 0.021). The only COA factor independently associated with SSI in the COA database included clean-contaminated wound classification (OR 3.887, 95% CI 1.354-11.153, p = 0.012), with public insurance (OR 1.966, 95% CI 0.957-4.041, p = 0.066) and spine procedures (OR 1.982, 95% CI 0.955-4.114, p = 0.066) approaching significance. Both NSQIP-P and COA multivariate model C-statistics were > 0.7. CONCLUSIONS The NSQIP-P SSI rates, but not risk factors, were similar to data from a single center.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Prevention and management of internal cerebrospinal fluid shunt infections

Cerebrospinal fluid (CSF) shunt infection is a serious and potentially devastating complication of CSF shunt placement. Younger age, previous CSF shunt infection or revision, and the type of the shunt are important risk factors for shunt infection. More than half of the cases are caused by Staphylococcus aureus and coagulase-negative staphylococci. The biofilm plays a central role in its pathogenesis. CSF cultures remain the gold standard for diagnosis of CSF shunt infection. The most effective way to prevent CSF shunt infection is optimization of sterile protocols and use of proper and timely antibiotic prophylaxis. Management of CSF shunt infection frequently requires removal of all shunt components, placement of a temporary external device, and administration of intravenous antibiotics, followed by reshunting at a later time. This review summarizes and analyses the results of previous reports of CSF shunt infection and assesses the prevention and management of this important entity.

Evidence-based interventions to reduce shunt infections: a systematic review

PURPOSE

Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence.

METHODS

A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included.

RESULTS

Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates.

CONCLUSION

Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.

Incidence and risk factors of ventriculoperitoneal shunt infections in children: a study of 333 consecutive shunts in 6 years

The major aims of this study were to estimate the infection rate and recognize the risk factor for ventriculoperitoneal (VP) shunt infections in children. To analyze shunt infection rate and identify risk factors, a retrospective cohort analysis of 333 consecutive VP shunt series was performed at Seoul National University Children's Hospital in Korea between January 2005 and February 2011. Overall, 35 shunts (10.5%) were infected, which represented an infection rate of 0.075 infection cases per shunt per year. VP shunt infection occurred at a median of 1 month (range, 6 days to 8 months) after insertion. An independent risk factor for shunt infection was undergoing an operation before the first year of life (relative risk 2.31; 95% confidence interval, 1.19-4.48). The most common causative microorganism was coagulase-negative staphylococci in 16 (45.7%) followed by Staphylococcus aureus in 8 (22.9%). Methicillin resistance rate was 83.3% among coagulase-negative staphylococci and S. aureus. In this study, cerebrospinal fluid shunt infection rate was 10.5%. Infection was frequently caused by methicillin-resistant coagulase-negative staphylococci and S. aureus within two months after shunt surgery. Vancomycin may be considered as the preoperative prophylaxis for shunt surgery in a situation where methicillin resistance rate is very high.

Cerebrospinal fluid shunt operations without cranial bandaging. Clinical article

OBJECT

Cranial bandages are commonly applied over scalp incisions immediately after cerebrospinal fluid (CSF) shunt surgery, putatively to prevent complications, particularly infection. These bandages require resources, consume the time of healthcare workers, and incur non-negligible expenses. It is therefore both reasonable and important to examine the efficacy of cranial bandaging.

METHODS

The combined experience of 3 neurosurgeons over 6.75 years with using no cranial bandaging after operations for implantation or revision of CSF shunts is the basis of this report. These data were prospectively accrued and retrospectively analyzed.

RESULTS

The infection rate was 4.2% (95% CI 3.1-5.6%) for 1064 operations performed without postoperative cranial bandaging after either shunt insertion or revision surgery through clean or clean-contaminated wounds. The age distribution extended from premature infants through adults 77 years of age.

CONCLUSIONS

The results of this investigation support the position that bandaging scalp wounds after CSF shunt implantation or revision surgery adds no benefit beyond the easier, simpler, faster, and cheaper practice of using antibiotic ointment as a dressing without bandaging.

Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures

OBJECTIVE

The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable on a routine basis and allowed the reduction of shunt infections (SI) in children.

MATERIALS AND METHODS

Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation, we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique; limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation; avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children aged <12 months; (3) procedures for shunt revision.

RESULTS

Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful.

CONCLUSION

These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical staff. This last issue will be evaluated further in the present ongoing protocol.