Antibiotic Impregnated External Ventricular Drains: Meta and Cost Analysis

Root, Brandon; Barrena, Benjamin G.; MacKenzie, Todd A.; Bauer, David F.

doi:10.1016/j.wneu.2015.09.032

Cited by 34 publications

(20 citation statements)

References 37 publications

(54 reference statements)

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“…[8] For this study, uniformity of collected data was paramount, and thus all ventriculostomy catheters included here were non-antibiotic impregnated Integra trauma catheters. [7151623] After the EVD has been sutured into place, a BioPatch is placed where the catheter exits the skin and a Tegaderm is placed to cover the BioPatch and catheter. As per standard neurosurgical protocol, a non-contrast Computerized Tomography (CT) scan was obtained after placement to rule out hemorrhage caused by placement and to confirm satisfactory placement of the catheter.…”

Section: Methodsmentioning

confidence: 99%

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

Hariri¹,

Farr²,

Lawandy³

et al. 2017

Surg Neurol Int

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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.

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Section: Methodsmentioning

confidence: 99%

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

Hariri¹,

Farr²,

Lawandy³

et al. 2017

Surg Neurol Int

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“…52 A recent meta-analysis showed a significant protective effect of antibiotic-impregnated EVDs against infections, with a number needed to treat of 19. 53 Other studies show a selective effect (silver-impregnated EVD catheters were shown to decrease the risk of CSF infections but only by Gram-positive organisms 54 ), or no effect at all (silver-coated catheters did not reduce days with antibiotics, days with EVD, or days in the ICU 39 ). Cost analysis studies have demonstrated that use of the more expensive impregnated catheters is supported.…”

Section: Prophylaxismentioning

confidence: 99%

Neurosurgical Infections

2019

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Patients in the neurointensive care unit often undergo life-saving neurosurgical interventions that can be associated with serious complications. Infection is a common and sometimes fatal complication of such procedures. Infection may occur not only in the setting of major cranial and spinal surgery, but also with common minor procedures that utilize neurosurgical devices, such as placement of external ventricular drains, ventriculoperitoneal shunts, and deep brain stimulators. In this article, we review the epidemiology and microbiology of these infections, and discuss their general and procedure-specific risk factors and treatment options.

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“…Complications associated with VPS failures are expensive to manage. [32][33][34][35][36][37][38] Consequently, the use of VPS catheters, which result in fewer complications, even if more expensive to purchase, could be costeffective or yield cost savings to the NHS. The economic analysis within the BASICS trial estimated that, although antibiotic-impregnated shunt catheters are about twice the price of standard silicone shunt catheters, this upfront cost could be justified by the reduced infection rate and associated cost savings of further surgery and prolonged hospital care.…”

Section: Cost Effectivenessmentioning

confidence: 99%

“…Analyses that considered the RR of VPS infection associated with antibioticimpregnated shunt catheters, determined from clinical trial data, are limited to three studies. [37][38][39] Root et al 37 All analyses have many limitations, not least the assumption that potential avoidance of the cost of managing VPS infections can be equated to a cost saving. Moreover, the analyses lacked any consideration of health outcomes associated with shunt catheter-associated infections or other potential causes of VPS failure.…”

Section: Chapter 4 Economic Evaluation Introductionmentioning

confidence: 99%

Silver-impregnated, antibiotic-impregnated or non-impregnated ventriculoperitoneal shunts to prevent shunt infection: the BASICS three-arm RCT

Mallucci

Jenkinson

Conroy

et al. 2020

Health Technol Assess

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Background Insertion of a ventriculoperitoneal shunt to treat hydrocephalus is one of the most common neurosurgical procedures worldwide. Shunt infection affects up to 15% of patients, resulting in long hospital stays, multiple surgeries and reduced cognition and quality of life. Objectives The aim of this trial was to determine whether or not antibiotic-impregnated ventriculoperitoneal shunts (hereafter referred to as antibiotic shunts) (e.g. impregnated with rifampicin and clindamycin) or silver-impregnated ventriculoperitoneal shunts (hereafter referred to as silver shunts) reduce infection compared with standard ventriculoperitoneal shunts (hereafter referred to as standard shunts). Design This was a three-arm, superiority, multicentre, parallel-group randomised controlled trial. Patients and a central primary outcome review panel, but not surgeons or operating staff, were blinded to the type of ventriculoperitoneal shunt inserted. Setting The trial was set in 21 neurosurgical wards across the UK and the Republic of Ireland. Participants Participants were patients with hydrocephalus of any aetiology who were undergoing insertion of their first ventriculoperitoneal shunt. Interventions Participants were allocated 1 : 1 : 1 by pressure-sealed envelope to receive a standard non-impregnated, silver-impregnated or antibiotic-impregnated ventriculoperitoneal shunt at the time of insertion. Ventriculoperitoneal shunts are medical devices, and were used in accordance with the manufacturer’s instructions for their intended purpose. Main outcome measures The primary outcome was time to ventriculoperitoneal shunt failure due to infection. Secondary outcomes were time to failure for any cause, reason for failure (infection, mechanical), types of ventriculoperitoneal shunt infection, rate of infection after first clean (non-infected) revision and health economics. Outcomes were analysed by intention to treat. Results Between 26 June 2013 and 9 October 2017, 1605 patients from neonate to 91 years of age were randomised to the trial: n = 36 to the standard shunt, n = 538 to the antibiotic shunt and n = 531 to the silver shunt. Patients who did not receive a ventriculoperitoneal shunt (n = 4) or who had an infection at the time of insertion (n = 7) were not assessed for the primary outcome. Infection occurred in 6.0% (n = 32/533) of those who received the standard shunt, in 2.2% (n = 12/535) of those who received the antibiotic shunt and in 5.9% (n = 31/526) of those who received the silver shunt. Compared with the standard shunt, antibiotic shunts were associated with a lower rate of infection (cause-specific hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80) and a decreased probability of infection (subdistribution hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80). Silver shunts were not associated with a lower rate of infection than standard shunts (cause-specific hazard ratio 0.99, 97.5% confidence interval 0.56 to 1.74). The ventriculoperitoneal shunt failure rate attributable to any cause was 25.0% overall and did not differ between arms. Antibiotic shunts save £135,753 per infection avoided. There were no serious adverse events. Limitations It was not possible to blind treating neurosurgeons to the ventriculoperitoneal shunt type. The return rate for patient-reported outcomes was low. Limitations to the economic evaluation included failure to obtain Hospital Episode Statistics data from NHS Digital, as per protocol. Reliance on patient-level information and costing systems data mitigated these limitations. Conclusions Antibiotic shunts have a reduced infection rate compared with standard shunts, whereas silver shunts do not. Antibiotic shunts are cost-saving. Future work A sample collection has been established that will enable the study of surrogate markers of ventriculoperitoneal shunt infection in cerebrospinal fluid or blood using molecular techniques. A post hoc analysis to study factors related to shunt failure will be performed as part of a future study. An impact analysis to assess change in practice is planned. Trial registration Current Controlled Trials ISRCTN49474281. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 17. See the NIHR Journals Library website for further project information.

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Antibiotic Impregnated External Ventricular Drains: Meta and Cost Analysis

Cited by 34 publications

References 37 publications

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

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

Neurosurgical Infections

Silver-impregnated, antibiotic-impregnated or non-impregnated ventriculoperitoneal shunts to prevent shunt infection: the BASICS three-arm RCT

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