Journal of Neurosurgery Oct 2011 / Vol. 115 / No. 4 / Pages 670-678. DOI: 10.3171/2011.5.JNS102003.

Many neurosurgeons remove their patients’ hair before surgery. They claim that this practice reduces the chance of postoperative surgical site infections, and facilitates planning, attachment of the drapes, and closure. However, most patients dread this procedure.

The authors performed the first systematic review on shaving before neurosurgical procedures to investigate whether this commonly performed procedure is based on evidence. They systematically reviewed the literature on wound infections following different shaving strategies. Data on the type of surgery, surgery-related infections, preoperative shaving policy, decontamination protocols, and perioperative antibiotics protocols were collected.

The search detected 165 articles, of which 21 studies—involving 11,071 patients—were suitable for inclusion. Two of these studies were randomized controlled trials. The authors reviewed 13 studies that reported on the role of preoperative hair removal in craniotomies, 14 on implantation surgery, 5 on bur hole procedures, and 3 on spine surgery. Nine studies described shaving policies in pediatric patients.

None of these papers provided evidence that preoperative shaving decreases the occurrence of postoperative wound infections. The authors conclude that there is no evidence to support the routine performance of preoperative hair removal in neurosurgery. Therefore, properly designed studies are needed to provide evidence for preoperative shaving recommendations.

Neurosurgery 69:625–629, 2011 DOI: 10.1227/NEU.0b013e31821bc435

Cerebrospinal fluid (CSF) shunt infection remains a major cause of morbidity and mortality in the treatment of hydrocephalus. Studies have demonstrated the efficacy of antibiotic-impregnated shunt (AIS) systems in reducing CSF shunt infections in pediatric patients. Fewer studies evaluate the efficacy of AIS systems in adult hydrocephalus.

OBJECTIVE: To determine whether categorical conversion to AIS shunt systems reduced the incidence of shunt infection in adults.

METHODS: All adult patients undergoing CSF shunt insertion over a 7-year period were retrospectively reviewed (2004-2009). In 2006, a categorical switch to AIS catheters was made. Before 2006, standard nonimpregnated shunt catheters were used. We retrospectively reviewed the first 250 cases of AIS catheter implantation and compared them with the immediately preceding 250 non-AIS cases to assess 1-year incidence of CSF shunt infection.

RESULTS: Five hundred shunt surgeries were performed for normal-pressure hydrocephalus in 378 patients (76%), pseudotumor cerebri in 83 patients (17%), and various obstructive/communicating hydrocephalus etiologies in 40 patients (8%). All patients were followed for 12 months. The mean age was 60 6 18 years. Baseline characteristics were similar between AIS (n = 250) and non-AIS (n = 250) cohorts. Overall, 13 patients (2.6%) experienced CSF shunt infection, occurring a mean of 2 6 2 months postoperatively. Shunt infection incidence was decreased in AIS (1.2%) vs non-AIS (4.0%) cohorts (P = .0492). Staphylococcus epidermidis was the most common pathogen in AIS and non-AIS cohorts. Oxacillin resistance was not increased in the AIS cohort.

CONCLUSION: Categorical conversion to AIS catheters was associated with a reduced incidence of shunt infection. AIS catheters may be a reliable instrument for decreasing perioperative shunt colonization and subsequent infection in adults with hydrocephalus.

J Neurosurg Pediatrics 8:22–29, 2011. DOI: 10.3171/2011.4.PEDS10551

Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).

Methods. The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.

Results. Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19–3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43–14.41; p = 0.01) were associated with an increased risk of infection.

Conclusions. The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.

Neurosurgery 68:996–1005, 2011 DOI: 10.1227/NEU.0b013e3182096d84

Ventriculostomy-related infection (VRI) is a severe complication of external ventricular drain use, occurring in 5% to 23% of patients. Preventive measures for VRI include prolonged prophylactic systemic antibiotics (PSAs) and an antibioticcoated external ventricular drains (ac-EVDs).

OBJECTIVE: We performed a systematic review of all studies evaluating PSAs and ac-EVD for VRI prevention through July 2010.

METHODS: Two reviewers independently assessed eligibility and evaluated study quality based on pre-established criteria. Observational studies and randomized clinical trials (RCTs) that fulfilled inclusion criteria were included in the meta-analysis.

RESULTS: Three RCTs and 7 observational studies met our inclusion criteria and were included in the analysis. The type of antibiotics and VRI definitions varied among these studies. Pooled analysis showed a protective effect of PSAs and ac-EVDs for VRI (risk ratio: 0.32; 95% CI: 0.18-0.56). Results showed moderate heterogeneity (I2 = 53%) explained by the difference in quality among the studies and the inclusion of 1 large positive cohort study. The effect of PSAs and ac-EVDs was unrelated to the type of study (RCT or observational, P for interaction = .55), the route of antibiotic administration (PSAs or ac-EVDs, P = .13), or the quality of the studies (suboptimal vs good/excellent, P = .55).

CONCLUSION: RCTs and observational-derived evidence support the use of PSAs throughout the duration of external ventricular drainage; similarly, the use of ac-EVDs to prevent VRI seems to be beneficial. Available data are heterogeneous and of suboptimal quality. Further research is needed to confirm the findings of this meta-analysis. There are not sufficient data to compare the protective effect of ac-EVDs and PSAs.

Acta Neurochir (2011) 153:647–651. DOI 10.1007/s00701-010-0905-1

Many strategies have been developed with the aim of reducing external ventricular drain-related infections. Antibiotic-impregnated catheters are one of them.

Material and methods We report 648 cases of external ventricular drain from a total of 534 patients treated at the Virgen del Rocío Hospital between 1995 and 2006. Three subgroups were considered: group 1 included patients treated between 1995 and 2000, as well as a total of 190 external ventricular drains and 59 cases of infection (31.05%); group 2, with patients treated between 2000 and 2004 and managed with a minimal handling protocol, included 210 external ventricular drains and nine cases of infection (4.29%); and group 3, treated between 2004 and 2006, with 248 external ventricular drains and six cases of infection (2.41%). This latter subgroup included patients managed with a minimal handling protocol and antibiotic-impregnated catheters.

Results Infection rate was 17% when non-antibioticimpregnated catheters were employed and 2.41% when antibiotic-impregnated catheters were inserted (p<0.001). This difference was statistically significant before and after the introduction of a minimal handling protocol, with percentages of 5.31% and 3.27%, respectively (p<0.001; odds ratio 0.08; absolute risk reduction 27.26%). However, no statistically significant difference was observed in infection rate when the impact of a minimal handling protocol was considered: 4.29% when only the protocol was introduced and 2.41% when both the protocol and antibiotic-impregnated catheters were used (p>0.05).

Conclusion Minimal handling protocols constitute an essential strategy in the reduction of external ventricular drain-related infections. Besides that, the use of antibiotic-impregnated catheters may reduce infection-related hospital costs.

Neurosurgery 67:1303–1310, 2010 DOI: 10.1227/NEU.0b013e3181f07e76

Reported infection rates after ventriculoperitoneal shunt surgery vary from 1 to 25%. Antibiotic-impregnated (AI) catheters may reduce shunt infection rates, but this is uncertain.

OBJECTIVE: To establish a prospective shunt registry to evaluate short-term (3-month) infection rates associated with ventriculoperitoneal shunts and standard or AI catheters during surgical treatment of hydrocephalus.

METHODS: A prospective, multicenter, noncontrolled, open-label registry investigated patients with de novo catheter implantation or catheter replacement of an existing ventriculoperitoneal shunt. The primary outcome was shunt infection.

RESULTS: A total of 440 patients were entered into the registry at 10 sites: 3 in North America, 2 in Singapore, 4 in China and 1 in India. Seven patients were excluded. Of the 433 remaining patients, 314 had new shunts and 119 were revisions. Shunt infections occurred in 14 of 433 patients (3.2%) overall and in 2 of 37 infants (5.2%) younger than 1 year. AI catheters were used in 46 of 433 patients at 7 centers. The shunt infection rate was 0 of 46 for shunts with AI catheters and 14 of 387 (3.6%) without AI catheters. Infection rates were similar with AI catheters, adjusting for age and catheter type.

CONCLUSION: The overall shunt infection rate was lower than in previous multicentered studies. The low infection rate and low rate of AI catheter use precludes any meaningful statement regarding the value of AI catheters in reducing the infection rate. Consideration should be given to performing a well designed, adequately powered, prospective randomized controlled trial to determine whether AI catheters reduce shunt infection rates.

J Neurosurg Pediatrics 6:000–000, 2010. DOI: 10.3171/2010.5.PEDS09457

Significant variation exists in the surgical and medical management of CSF shunt infection. The objectives of this study were to determine CSF shunt reinfection rates following initial CSF shunt infection in a large patient cohort and to determine management, patient, hospital, and surgeon factors associated with CSF shunt reinfection.

Methods. This retrospective cohort study included children who were in the Pediatric Health Information System (PHIS) database, who ranged in age from 0 to 18 years, and who underwent uncomplicated initial CSF shunt placement in addition to treatment for initial CSF shunt infection between January 1, 2001, and December 31, 2008. The outcome was CSF shunt reinfection within 6 months. The main predictor variable of interest was surgical approach to treatment of first infection, which was determined for 483 patients. Covariates included patient, hospital, surgeon, and other management factors.

Results. The PHIS database includes 675 children with initial CSF shunt infection. Surgical approach to treatment of the initial CSF shunt infection was determined for 483 children (71.6%). The surgical approach was primarily shunt removal/new shunt placement (in 286 children [59.2%]), but a substantial number underwent externalization (59 children [12.2%]), of whom a subset went on to have the externalized shunt removed and a new shunt placed (17 children [3.5% overall]). Other approaches included nonsurgical management (64 children [13.3%]) and complete shunt removal without shunt replacement (74 children [15.3%]). The 6-month reinfection rate was 14.8% (100 of 675 patients). The median time from infection to reinfection was 21 days (interquartile range [IQR] 5–58 days). Children with reinfection had less time between shunt placement and initial infection (median 50 vs 79 days, p = 0.06). No differences between those with and without reinfection were seen in patient factors (patient age at either shunt placement or initial infection, sex, race/ethnicity, payer, indication for shunt, number of comorbidities, distal shunt location, and number of shunt revisions at first infection); hospital volume; surgeon volume; or other management factors (for example, duration of intravenous antibiotic use). Nonsurgical management was associated with reinfection, and complete shunt removal was negatively associated with reinfection. However, reinfection rates did not differ between the 2 most common surgical approaches: shunt removal/new shunt placement (44 [15.4%] of 286; 95% CI 11.4%–20.1%) and externalization (total 12 [20.3%] of 59; 95% CI 11.0%–32.8%). Externalization followed by shunt removal/new shunt placement (5 [29.4%] of 17; 95% CI 10.3%–56.0%) and nonsurgical management (15 [23.4%] of 64; 95% CI 13.8%–35.7%) had higher, but nonstatistically significant, reinfection rates. The length of stay was shorter for nonsurgical management.

Conclusions. Surgical approach to treatment of initial CSF shunt infection was not associated with reinfection in this large cohort of patients.

In select patient populations, hyperglycemia has been shown to increase the risk of surgical site infection (SSI), whereas stringent glucose control has improved outcomes. To date, no study has focused on whether SSIs in patients with brain tumors undergoing resection are associated with hyperglycemia. Methods. The authors performed a retrospective chart review of patients who underwent a craniotomy after receiving a diagnosis of brain tumor. From 2001 to 2008, 2485 patients underwent a craniotomy for tumor resection at the Brain Tumor & Neuro-Oncology Center at the Cleveland Clinic. Fifty-seven of these patients (2.3%) developed SSIs postoperatively. A matched case-control study design was used, with 57 patients who developed SSIs after craniotomy (cases) matched with 57 patients who did not develop SSIs (controls). The results were analyzed using both univariate and multivariate conditional logistic regression. Results. Glucose level was not a significant factor in postoperative SSI (p = 0.83) after adjusting for duration of surgery and adherence to antibiotic prophylaxis. However, duration of surgery was significantly associated with postoperative SSI (p = 0.047). Conclusions. For patients who undergo craniotomy for definitive resection of a brain tumor, duration of surgery described more variation in the model to predict SSI than blood glucose levels.

Object. An important complication of external CSF drainage is bacterial meningitis or ventriculitis, resulting in increased morbidity, mortality, and health care costs. In 2003, a high rate (37%) of probable drain-related infections was identified at the authors’ hospital. A multidisciplinary working group was installed to reduce this incidence to < 10% within 1.5 years.

Methods. An intervention strategy based on 5 pillars (increased awareness, focused standard operating procedures, a diagnostic and therapeutic algorithm, timely administration of prophylaxis, and improvement of the drainage system) was designed and implemented from 2004 to 2006. During this period all patients with external CSF drainage were prospectively monitored.

Results. Between 2004 and 2006, there were 467 patients in whom 579 drains (external ventricular and exter- nal lumbar) had been placed. The overall incidence of drain-related infections was 16.2% in 2004, 8.9% in 2005, and 11.3% in 2006. For external lumbar drains the number of infections per 100 drain days was 2.4 in 2004, 0.6 in 2005, and 0.8 in 2006. For external ventricular drains these rates were 1.7, 1.0, and 1.2, respectively. Meanwhile, the causative noncutaneous microorganisms, indicative for systemic-contamination during manipulation, decreased. By retrospective analysis, the proportion of patients with a probable drain-related infection decreased from 37% in 2003 to 9% in 2005 and 2006.

Conclusions. The authors’ multidisciplinary approach in which different preventive measures were combined was associated with a significant reduction in the incidence of drain-related secondary meningitis, and thus provides an important improvement of patient safety.

BACKGROUND:The average hospital cost for shunt infection treatment is $50 000, making it the most financially costly implant-related infection in the United States. We set out to determine whether introduction of antibiotic-impregnated shunts (AISs) in our practice has decreased the incidence of shunt infection or decreased infection-related hospital costs at our institution.

METHODS: Clinical and hospital billing records of pediatric patients undergoing cerebrospinal fluid (CSF) shunt insertion at a single institution from April 2001 to December 2006 were retrospectively reviewed. Eighteen months before October 2002, all CSF shunts included standard, non-AIS catheters. During the 4 years after October 2002, all CSF shunts included AIS catheters. Patients were followed at least 18 months after surgery.

RESULTS: A total of 406 pediatric patients underwent 608 shunt placement procedures (400 AISs, 208 non-AISs). Of patients with non-AIS catheters, 25 (12%) experienced shunt infection, whereas only 13 patients (3.2%) with AIS catheters experienced shunt infection during follow-up (P < .001). The total hospital cost to treat 25 non-AIS shunt infections over the first 18 months was $1,234,928. The total hospital cost to treat 13 AIS shunt infections over the past 4 years was $606,328. The mean hospital cost per shunt infection was similar for infected AIS and non-AIS catheters ($46 640 vs. $49 397). However, the infection- related hospital cost per 100 patients shunted was markedly lower in the AIS cohort than in the non-AIS cohort ($151 582 vs. $593 715).

DISCUSSION: The introduction of AIS catheters in our institutional practice reduced the incidence of shunt infection and resulted in significant hospital cost savings. AIS systems are efficient and cost-effective instruments to prevent perioperative colonization of CSF shunt components.