Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated With Reinfection

Abstract

Background. The relationship between first and subsequent cerebrospinal fluid (CSF) shunt infections is poorly understood. By understanding the factors associated with increased risk of reinfection, researchers may provide optimal treatment strategies at the time of first infection. The objective of this study was to describe and compare children with and without CSF shunt reinfection. Methods. A retrospective cohort study was performed among 118 children who underwent initial CSF shunt placement and developed first CSF shunt infection. The primary outcome variable was CSF shunt reinfection. Patient risk factors and medical and surgical management of initial CSF shunt placement and first CSF shunt infection were compared between children with and without reinfection. Results. Of 118 children with first infection, 31 (26%) developed a reinfection during the study period (overall median follow-up, 2096 days). Factors associated with reinfection in this cohort included ventriculoatrial or complex shunt at initial CSF shunt placement, complications after first CSF shunt infection, and intermittent negative CSF cultures. Conclusions. Few patient or treatment factors were associated with reinfection. Factors associated with difficult-to-treat first CSF shunt infection, including complications after first CSF shunt infection and intermittent negative CSF cultures, were associated with reinfection. Clinicians who treat patients with unusual CSF shunts or more difficult first infections should have a high index of suspicion for reinfection after treatment is completed.

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

“…It should be noted, however, that treatment for patients in this study was not standardized, with different surgical strategies used for shunt removal and replacement, as well as antimicrobial choices. A second large cohort study of 675 patients followed after first infection noted a mean duration of therapy of 7.5 days in 15% of those who experienced reinfection compared to 9 days of treatment in those who did not experience reinfection (differences not significant) [142]. …”

“…In a recent study in children, risk factors identified for reinfection were those with complex shunts (multiple shunts placed or any single shunt with multiple catheters together), an atrial shunt, any complication after the first infection (ie, shunt malfunction, hemorrhage, CSF leak), or intermittent negative cultures defined as positive CSF cultures clearing and then returning over the course of treatment [142]. …”

Cerebrospinal Fluid Shunting Complications in Children

“…Reinfection following a primary shunt infection is a challenge that plagues hydrocephalus treatment, occurring in 26% of pediatric patients [84] . Interestingly, patient factors, treatment, and diagnostic factors matter less than evidence of difficulty clearing the primary shunt infection, with intermittent clearance and reemergence of the pathologic organism on serial CSF cultures during the treatment course serving as a negative prognostic indicator [84].…”

“…Interestingly, patient factors, treatment, and diagnostic factors matter less than evidence of difficulty clearing the primary shunt infection, with intermittent clearance and reemergence of the pathologic organism on serial CSF cultures during the treatment course serving as a negative prognostic indicator [84]. New research aims at understanding the role of established inflammatory schemes, including the influx of activated M2 macrophages, neutrophils, and chemokines CXCL1, CCL2, and IL-17 in the presence of bacterial biofilm-infected shunt hardware [85, 86].…”

Anatomy-Based navigation for ventriculostomy: Nasion-coronal suture distance measurement

“…Contamination of the ventricular catheter at the scalp tract overlying the drill site is thus a potentially important source of infections. With skin incision in the smallest possible level, subcutaneous tissue and the ventricular catheter parts fewer contact with the flora and primarily to prevent infection may be as many complications [12][13][14][15][16][17][18][19][20][21].…”