A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections

Abstract

BackgroundVentriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI.MethodsRelevant studies were identified from MEDLINE and EMBASE and from reference searching of included studies and recent review articles on relevant topics. The Newcastle-Ottawa Scale was used to assess quality and risk of bias. A random effects model was used to pool individual study estimates and 95% confidence intervals (CI) were calculated using the exact Poisson method. Heterogeneity was assessed using the heterogeneity χ2 and I-squared tests. Subgroup analyses were performed and a funnel plot constructed to assess publication bias.ResultsThere were a total of 35 studies which yielded 752 infections from 66,706 catheter-days of observation. The overall pooled incidence rate of VAI was 11.4 per 1000 catheter days (95% CI 9.3 to 13.5), for high quality studies the rate was 10.6 (95% CI 8.3 to 13) and 13.5 (95% CI 8.9 to 18.1) for low quality studies. Studies which had mean duration of EVD treatment of less than 7 days had a pooled VAI rate of 19.6 per 1000 catheter-days, those with mean duration of 7–10 days had VAI rate of 12.8 per 1000 catheter-days and those with mean duration greater than 10 days had VAI rate of 8 per 1000 catheter-days. There was significant heterogeneity for the primary outcome (p = 0.004, I-squared = 44%) and most subgroups. The funnel plot did not show evidence for publication bias.ConclusionsThe incidence rate of VAI is 11.4 per 1000 catheter-days. Further research should focus on analysis of risk factors for VAI and techniques for reducing the rate of VAI.

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

“…In patients with external ventricular drains, the incidence of ventriculitis has ranged from 0% to 22%. In a large metaanalysis of 35 studies that yielded 752 infections from 66 706 catheter-days of observation [21], the overall pooled incidence of external ventricular drain-related CSF infection was 11.4 per 1000 catheter-days (95% confidence interval [CI], 9.3-13.5); for high-quality studies, the incidence was 10.6 per 1000 catheter-days (95% CI, 8.3-13). Factors associated with an increased risk of infection are intraventricular or subarachnoid hemorrhage, cranial fracture with CSF leak, catheter irrigation, craniotomy, and duration of catheterization.…”

External Ventricular Drainage Infections: Experience From a Tertiary Care Center in Nepal

“…4 In a meta analysis conducted by Ramanan et al in 2014 including 35 studies, majority of infections were caused by gram positive bacteria, predominantly by coagulase-negative staphylococci (39%, including S. epidermidis) and S. aureus (15%). 10 In our study, Acinetobacter baumanni was most commonly sensitive to Tigicycline and Polymixin B and resistant to carbapenems and other beta-lactam antibiotics, while Burkholderia cepacia was commonly sensitive to Cotrimoxazole and Amikacin.…”

“…1 Pfi sterer in 2003, noted majority of infections were caused by Staphylococcus epidermidis. 10 Rath et al in 2014, noted oagulase negative Staphylococci accounting for majority (62%) of the infections. 11 Similarly, Hagel et al in 2014 found the majority of infections caused by coagulasenegative Staphylococcus.…”

“…High fever with neurological defi cits and an elevated leukocyte count in the CSF favor an infection. 10 In most cases with an external ventricular drainage the diagnosis of CSF infection is based on laboratory fi ndings. In our study, the CSF cell count of the samples with positive bacteriological cultures were analyzed the same day.…”

Comparison of Rates of Drain-Related Ventriculitis According to Definitions Used

“…[3][4][5] The latter metric better reflects the risk associated with device duration. Ramanan et al 5 reviewed 35 studies, which included 752 infections, and found that the rate was lower for high-quality studies than for lower-quality studies.…”