Risk Factors for First Cerebrospinal Fluid Shunt Infection: Findings from a Multi-Center Prospective Cohort Study

Simon, Tamara D.; Butler, J.V.; Whitlock, Kathryn B.; Browd, Samuel R.; Holubkov, Richard; Kestle, John R. W.; Kulkarni, Abhaya V.; Langley, Marcie; Limbrick, David D.; Mayer-Hamblett, Nicole; Tamber, Mandeep S.; Wellons, John C.; Whitehead, William E.; Riva-Cambrin, Jay

doi:10.1016/j.jpeds.2014.02.013

Cited by 117 publications

(94 citation statements)

References 36 publications

(39 reference statements)

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“…This in agreement with previous cohorts that report an infection rate of 6-8 % but lower than a recently published, large multicenter study that reported an infection rate of 11.7 % per patient [14]. The risk of developing a shunt infection is strongly correlated with increasing number of revision surgeries [15]. In our study, a treated VAD infection prior to shunt placement was not a risk factor for developing shunt infection in the future.…”

Section: Vad Infection Ratesupporting

confidence: 92%

Ventricular access device infection rate: a retrospective study and review of the literature

et al. 2014

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Purpose Ventricular access devices (VAD) are often used for treatment of posthemorrhagic hydrocephalus (PHH) in preterm infants. The reported rates of infection have varied and range from 0 to 22 %. The objective of our study is to present our VAD associated infection at our institution. Methods The charts for patients that had VADs inserted between May 1, 2009 and October 31, 2013 at a single institution (Children's Healthcare of Atlanta) were retrospectively reviewed. The number of VAD infections, defined as either cerebrospinal fluid (CSF)-positive cultures or wound complication, was recorded. Of patients that survived, the number of VAD to shunt conversions was also examined. The data from 15 previously published studies were pooled to determine overall VAD infection and VAD to shunt conversion rates. Results A total of 142 VADs were placed. There were 13 infections (9.2 %), 11 of which had CSF-positive cultures (7.7 %). There were two wound complications with negative CSF cultures. Six patients died after VAD placement for reasons unrelated to their VAD surgeries (4.2 %). In the remaining patients, there were 113 VAD to shunt conversions (83.1 %). Fifteen studies that reported VAD infections were analyzed; an overall infection rate of 7.0 % and VAD to shunt conversion rate of 79 % were calculated. Conclusions While VAD is a valuable tool to treat PHH, it remains a procedure with an infection rate between 7.0 and 8.0 %. Close follow-up is needed to capture these adverse events as early as possible. Approximately 80 % of patients with PHH will require permanent CSF diversion.

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Section: Vad Infection Ratesupporting

confidence: 92%

Ventricular access device infection rate: a retrospective study and review of the literature

et al. 2014

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“…This failure rate appears to be driven by shunt malfunction rather than shunt infection as the endoscope was not significantly associated (OR 1.45 [0.97-2.13]) with shunt infection in a previous HCRN study. 18 Our study found that this harm was specific to the endoscope as the other surgical adjuncts used to direct the proximal catheters (ultrasound and frameless stereotaxy) were associated with neither CSF shunt failure nor a trend toward diminished shunt survival. Considering the evidence, we would not recommend the routine use of the endoscope for the insertion of a child's initial CSF shunt.…”

Section: Discussionmentioning

confidence: 65%

Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study

Riva-Cambrin

Kestle

Holubkov

et al. 2016

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OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori–defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1–2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0–2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2–2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor—an existing cardiac comorbidity—was also associated with shunt failure.

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“…This is logical, as it appears a direct communication between the peritoneal cavity and the skin would confer increased risk of infection in ventriculoperitoneal shunts. 40 Unfortunately, neither our study nor theirs could collect data on the timing of GT placement compared with shunt insertion, so our understanding of that correlation is limited. Nabika et al, however, retrospectively assessed a small cohort of 23 adult patients in Hiroshima and concluded that there was an increased risk of infection when a percutaneous endoscopic gastrostomy was placed within a month after ventriculoperitoneal shunt placement.…”

Section: Other Variables Associated With Shunt Infectionmentioning

confidence: 96%

“…40 They found that the presence of a GT resulted in a 2-fold increased risk of infection in their multivariate analysis. This is logical, as it appears a direct communication between the peritoneal cavity and the skin would confer increased risk of infection in ventriculoperitoneal shunts.…”

Section: Other Variables Associated With Shunt Infectionmentioning

confidence: 96%

“…7,11,18,21,23,24,31,34,35,40,47 Shunt infection causes significant morbidity for patients, including prolonged hospitalization, repeated surgery, lengthy exposure to antibiotics, increased deaths, and possible intellectual consequences. 34 The economic impact of hydrocephalus and associated shunt failure or infection exceeds a billion dollars annually in the US.…”

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confidence: 99%

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Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

Beckman

Amankwah²,

Tetreault

et al. 2015

PED

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OBJECT The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon’s cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates. METHODS This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children’s Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children’s hospital (All Children’s Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models. RESULTS A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03–0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04–0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05–9.50, p = 0.04, and HR 2.82, 95% CI 1.33–5.96, p = 0.007, respectively). CONCLUSIONS This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

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Risk Factors for First Cerebrospinal Fluid Shunt Infection: Findings from a Multi-Center Prospective Cohort Study

Cited by 117 publications

References 36 publications

Ventricular access device infection rate: a retrospective study and review of the literature

Ventricular access device infection rate: a retrospective study and review of the literature

Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

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