Abstract
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.
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References
Bondurant CP, Jimenez DF (1995) Epidemiology of cerebrospinal fluid shunting. Pediatr Neurosurg 23:254–258
Patwardhan RV, Nanda A (2005) Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 56:139–145
Simon TD, Riva-Cambrin J, Srivastava R, Bratton SL, Dean JM, Kestle JRW, Hydrocephalus Clinical Research Network (2008) Hospital care for children with hydrocephalus in the United States: utilization, charges, comorbidities, and deaths. J Neurosurg Pediatr 1:131–137
Browd SR, Ragel BT, Gottfried ON, Kestle JRW (2006) Failure of cerebrospinal fluid shunts: part i: obstruction and mechanical failure. Pediatr Neurol 34:83–92
Duhaime A-C (2006) Evaluation and management of shunt infections in children with hydrocephalus. Clin Pediatr (Phila) 45:705–713
Simon TD, Hall M, Riva-Cambrin J, Albert JE, Jeffries HE, LaFleur B, Dean JM, Kestle JR, Hydrocephalus Clinical Research Network (2009) Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. J Neurosurg Pediatr 4:156–165
Reddy GK, Bollam P, Caldito G (2012) Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg 78:155–163
Jeelani NU O, Kulkarni AV, DeSilva P, Thompson DNP, Hayward RD (2009) Postoperative cerebrospinal fluid wound leakage as a predictor of shunt infection: a prospective analysis of 205 cases. J Neurosurg Pediatr 4:166–169
McGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ (2003) Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 36:858–862
Shannon CN, Simon TD, Reed GT, Franklin FA, Kirby RS, Kilgore ML, Wellons JC 3rd (2011) The economic impact of ventriculoperitoneal shunt failure. J Neurosurg Pediatr 8:593–599
Attenello FJ, Garces-Ambrossi GL, Zaidi HA, Sciubba DM, Jallo GI (2010) Hospital costs associated with shunt infections in patients receiving antibiotic-impregnated shunt catheters versus standard shunt catheters. Neurosurgery 66:284–289
Ratilal B, Costa J, Sampaio C (2006) Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev CD005365
Parker SL, Anderson WN, Lilienfeld S, Megerian JT, McGirt MJ (2011) Cerebrospinal shunt infection in patients receiving antibiotic-impregnated versus standard shunts. J Neurosurg Pediatr 8:259–265
Eymann R, Chehab S, Strowitzki M, Steudel W-I, Kiefer M (2008) Clinical and economic consequences of antibiotic-impregnated cerebrospinal fluid shunt catheters. J Neurosurg Pediatr 1:444–450
Klimo P Jr, Thompson CJ, Ragel BT, Boop FA (2011) Antibiotic-impregnated shunt systems versus standard shunt systems: a meta- and cost-savings analysis. J Neurosurg Pediatr 8:600–612
Richards HK, Seeley HM, Pickard JD (2009) Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry. J Neurosurg Pediatr 4:389–393
Thomas R, Lee S, Patole S, Rao S (2012) Antibiotic-impregnated catheters for the prevention of CSF shunt infections: a systematic review and meta-analysis. Br J Neurosurg 26:175–184
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. PLoS Med 6:e1000097
Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H (2011) Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document). Oxf Cent Evid-Based Med. http://www.cebm.net/index.aspx?o=5653
Hommelstad J, Madsø A, Eide PK (2013) Significant reduction of shunt infection rate in children below 1 year of age after implementation of a perioperative protocol. Acta Neurochir (Wien) 155:523–531
Kestle JR, Hoffman HJ, Soloniuk D, Humphreys RP, Drake JM, Hendrick EB (1993) A concerted effort to prevent shunt infection. Childs Nerv Syst 9:163–165
Pirotte BJM, Lubansu A, Bruneau M, Loqa C, Van Cutsem N, Brotchi J (2007) Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst 23:1251–1261
Mottolese C, Grando J, Convert J, Abdoulrahman M, Lelievre H, Vandenesch F, Bret P, Lapras C (2000) Zero rate of shunt infection in the first postoperative year in children–dream or reality? Childs Nerv Syst 16:210–212
Rotim K, Miklic P, Paladino J, Melada A, Marcikic M, Scap M (1997) Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 13:584–587
Kestle JRW, Riva-Cambrin J, Wellons JC 3rd, Kulkarni AV, Whitehead WE, Walker ML, Oakes WJ, Drake JM, Luerssen TG, Simon TD, Holubkov R, Hydrocephalus Clinical Research Network (2011) A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. J Neurosurg Pediatr 8:22–29
Choux M, Genitori L, Lang D, Lena G (1992) Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:875–880
Welch K (1979) Residual shunt infection in a program aimed at its prevention. Z Kinderchir Grenzgeb 28:374–377
Haliasos N, Bhatia R, Hartley J, Thompson D (2012) Ioban drapes against shunt infections? Childs Nerv Syst 28:509–510
Theophilus SC, Adnan JS (2011) A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection. Malays J Med Sci 18:30–37
Hayashi T, Shirane R, Yokosawa M, Kimiwada T, Tominaga T (2010) Efficacy of intraoperative irrigation with saline for preventing shunt infection. J Neurosurg Pediatr 6:273–276
Rehman A-U, Rehman T-U, Bashir HH, Gupta V (2010) A simple method to reduce infection of ventriculoperitoneal shunts. J Neurosurg Pediatr 5:569–572
Eymann R, Kiefer M (2010) Glue instead of stitches: a minor change of the operative technique with a serious impact on the shunt infection rate. Acta Neurochir Suppl 106:87–89
Rozzelle CJ, Leonardo J, Li V (2008) Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial. J Neurosurg Pediatr 2:111–117
Nejat F, Tajik P, El Khashab M, Kazmi SS, Khotaei GT, Salahesh S (2008) A randomized trial of ceftriaxone versus trimethoprim-sulfamethoxazole to prevent ventriculoperitoneal shunt infection. J Microbiol Immunol Infect 41:112–117
Tulipan N, Cleves MA (2006) Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 104:5–8
Ratanalert S, Musikawat P, Oearsakul T, Saeheng S, Chowchuvech V (2005) Non-shaved ventriculoperitoneal shunt in Thailand. J Clin Neurosci 12:147–149
Horgan MA, Piatt JH Jr (1997) Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 26:180–184
Faillace WJ (1995) A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Surg Neurol 43:344–350
Hirsch JF, Renier D, Pierre-Kahn A (1978) Influence of the use of a surgical isolator on the rate of infection in the treatment of hydrocephalus. Childs Brain 4:137–150
Tacconelli E, Cataldo MA, Albanese A, Tumbarello M, Arduini E, Spanu T, Fadda G, Anile C, Maira G, Federico G, Cauda R (2008) Vancomycin versus cefazolin prophylaxis for cerebrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. J Hosp Infect 69:337–344
Ragel BT, Browd SR, Schmidt RH (2006) Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:242–247
Parsons HM (1974) What Happened at Hawthorne? New evidence suggests the Hawthorne effect resulted from operant reinforcement contingencies. Science 183:922–932
Broekman MLD, van Beijnum J, Peul WC, Regli L (2011) Neurosurgery and shaving: what’s the evidence? J Neurosurg 115:670–678
Sebastian S (2012) Does preoperative scalp shaving result in fewer postoperative wound infections when compared with no scalp shaving? A systematic review. J Neurosci Nurs 44:149–156
Tanner J, Norrie P, Melen K (2011) Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev CD004122
Darouiche RO, Wall MJ, Itani KMF, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH (2010) Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 362:18–26
Noorani A, Rabey N, Walsh SR, Davies RJ (2010) Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery. Br J Surg 97:1614–1620
Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A (2013) Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 3, CD003949
Gruber TJ, Riemer S, Rozzelle CJ (2009) Pediatric neurosurgical practice patterns designed to prevent cerebrospinal fluid shunt infection. Pediatr Neurosurg 45:456–460
Conflict of interest
AGM is a consultant for Spinal Modulation and Functional Neuromodulation. AGM has distribution rights related to intellectual property with ATI, Cardionomics and Enspire. RJW was supported by the Melvin Burkhardt chair in neurosurgical oncology and the Karen Colina Wilson research endowment within the Brain Tumor and Neuro-oncology Center at the Cleveland Clinic. None of the funders played a role in data collection, analysis, interpretation, or the writing or editing of the manuscript.
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Sarmey, N., Kshettry, V.R., Shriver, M.F. et al. Evidence-based interventions to reduce shunt infections: a systematic review. Childs Nerv Syst 31, 541–549 (2015). https://doi.org/10.1007/s00381-015-2637-2
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DOI: https://doi.org/10.1007/s00381-015-2637-2