Effect of topical and intraventricular antibiotics used during ventriculoperitoneal shunt insertion on the rate of shunt infection—a meta‐analysis

Acta Neurochirurgica (2022) 164:1793–1803

The ventriculoperitoneal shunt is one of the most commonly performed neurosurgical procedures. One of the avoidable complications of shunt surgery is shunt infection. This PRISMA-compliant meta-analysis analysed the effectiveness of topical and/or intraventricular antibiotics in preventing shunt infections in patients undergoing shunt surgery.

Methods Four databases were searched from inception to 30th June 2021. Only original articles comparing the rate of shunt infection with and without antibiotics were included. Random-effects meta-analysis was used to compare the effect of the use of antibiotics in preventing infection and subgroup analysis for finding differences in various antibiotics.

Results The rate of shunt infection was 2.24% (53 out of 2362) in the topical antibiotic group in comparison to 5.24% (145 out of 2764) in the control group (p = 0.008). Subgroup analysis revealed that there is no significant difference between the antibiotics used.

Conclusions Our meta-analysis found that the risk of shunt infection is significantly reduced with the use of topical and intraventricular antibiotics without any serious adverse effect. No side effects of topical or intraventricular antibiotics were reported in the included studies. Further prospective studies are required to establish the safety and optimal dosage of topical antibiotics for them to be used routinely in neurosurgical practice. They can be used in patients at high risk of developing shunt infections till such studies are available.

Antibiotic-impregnated shunts: effects in pediatric population


J Neurosurg Pediatrics 13:101–106, 2014

Infection after both primary and revision shunt surgeries remains a major problem in pediatric neurosurgical practice. Antibiotic-impregnated shunt (AIS) tubing has been proposed to reduce infection rates. The authors report their experience with AIS catheters in their large pediatric neurosurgery department.

Methods. The authors conducted a retrospective case review of consecutive shunt operations performed before (1993–2003) and after (2005–2009) introduction of AIS tubing, with analysis of shunt infection rates and causative organisms identified.

Results. The historical control group consisted of 1592 consecutive shunt operations (657 primary insertions), and the AIS study group consisted of 500 consecutive shunt operations (184 primary insertions). Patients ranged in age from 0–17 years. In the historical group, 135 infections were identified (8.4%). In the AIS study group, 25 infections were identified (5%), representing a significant reduction (p < 0.005). The latency to diagnosis of infection was 23 days in the historical group and 139 days in the AIS study group. The infection rates in infants 0–6 months of age were 12.2% (historical group) and 6.7% (AIS group, p < 0.005), and in infants 7–12 months of age the rates were 7.9% (historical group) and 2.7% (AIS group, p < 0.005). In the historical control group, the frequency rank order of causative organisms was coagulase-negative staphylococcus (51.9%), Staphylococcus aureus (31.6%), streptococcus or enterococcus spp. (8.8%), gram-negative organisms (4.4%), and Propionibacterium acnes (2.2%). Organisms responsible for infections in AIS were S. aureus (40%), followed by streptococcus or enterococcus spp. (20%), P. acnes and coagulase-negative staphylococcus (both 16%), and gram-negative organisms (4%). No unusually antibioticresistant bacteria were identified in either group. The authors further subdivided the AIS group into those undergoing primary AIS insertion (Subgroup 1), those undergoing revision of non-AIS systems using AIS components (Subgroup 2), and those undergoing revision of AIS systems using AIS components (Subgroup 3). Infection rates were 1.6% in Subgroup 1, 2.5% in Subgroup 2, and 11.7% in Subgroup 3. Staphylococcus aureus was the most common organism identified in infections of the Subgroups 2 and 3.

Conclusions. Use of AIS tubing significantly improves shunt infection rates in both general pediatric and infant populations with no evidence of increased antibiotic resistance, which is in agreement with previous studies. However, the increased infection rate in revision surgery in children with AIS catheters in situ raises questions about their long-term application.

Morbidity of Ventricular Cerebrospinal Fluid Shunt Surgery in Adults: An 8-Year Study

Neurosurgery 68:985–995, 2011 DOI: 10.1227/NEU.0b013e318208f36

Cerebrospinal fluid (CSF) shunt procedures have dramatically reduced the morbidity and mortality rates associated with hydrocephalus. However, despite improvements in materials, devices, and surgical techniques, shunt failure and complications remain common and may require multiple surgical procedures.

OBJECTIVE: To evaluate CSF shunt complication incidence and factors that may be associated with increased shunt dysfunction and infection rates in adults.

METHODS: From January 1999 to December 2006, we conducted a prospective surveillance program for all neurosurgical procedures including reoperations and infections. Patients undergoing CSF shunt placement were retrospectively identified among patients labeled in the database as having a shunt as a primary or secondary intervention. Revisions of shunts implanted in another hospital or before the study period were excluded, as well as lumbo- or cyst-peritoneal shunts. Shunt complications were classified as mechanical dysfunction or infection. Follow-up was at least 2 years. Potential risk factors were evaluated using log-rank tests and stepwise Cox regression models.

RESULTS: During the 8-year surveillance period, a total of 14 275 patients underwent neurosurgical procedures, including 839 who underwent shunt placement. One hundred nineteen patients were excluded, leaving 720 study patients. Mechanical dysfunction occurred in 124 patients (17.2%) and shunt infection in 44 patients (6.1%). These 168 patients required 375 reoperations. Risk factors for mechanical dysfunction were atrial shunt, greater number of previous external ventriculostomies, and male sex; risk factors for shunt infection were previous CSF leak, previous revisions for dysfunction, surgical incision after 10 AM, and longer operating time.

CONCLUSION: Shunt surgery still carries a high morbidity rate, with a mean of 2.2 reoperations per patient in 23.3% of patients. Our risk-factor data suggest methods for decreasing shunt-related morbidity, including peritoneal routing whenever possible and special attention to preventing CSF leaks after craniotomy or external ventriculostomy.

A Multicenter Multinational Registry for Assessing Ventriculoperitoneal Shunt Infections for Hydrocephalus

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.

Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry

J Neurosurg Pediatrics 4:389–393, 2009. (DOI: 10.3171/2009.4.PEDS09210)

In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introduced to the United Kingdom (UK) market. These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis. The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design.

Methods. The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures. The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known about diagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures.

Results. Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test).

Conclusions. The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.

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