Evaluation of Antibiotic-Impregnated Shunt Catheters in Prevention of Shunt Infections: A Systematic Review

Abstract

Background: Cerebrospinal fluid (CSF) shunts remain among the most failure-prone lifesustaining medical devices implanted in modern medical practice, with failure rates of 30-40% at 1 year and approximately 50% at 2 years in pediatric patients. Aim of the Work: To study the effectiveness of antimicrobial impregnated catheters in preventing shunt and EVD infections and the impact of antibiotic impregnated catheters on mortality, and prevention colonization. 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. Conclusion: The use of antimicrobial shunt catheters reduces the risk for CSF infections in patients with hydrocephalus. Several subgroup analyses showed that factors related to study design, type of catheter, duration of catheter placement, and whether the procedure is a de novo implantation or a revision may affect this risk. Publication bias in the region of small negative trials was also observed.