Skip to main content

Advertisement

SpringerLink
Log in

Antibiotic-impregnated ventriculoperitoneal shunts—a multi-centre British paediatric neurosurgery group (BPNG) study using historical controls

  • Original Paper
  • Published:
Child's Nervous System Aims and scope Submit manuscript

Abstract

Background

Ventriculoperitoneal shunt infection remains a significant problem. The introduction of antibiotic-impregnated shunt (AIS) systems in the prevention of shunt infection may represent a potential advance; however, there are no randomized controlled trials to establish a robust evidence-based practice. Previously published single-institution cohort studies have provided varying results on the efficacy of AIS systems in the prevention of shunt infection. In this study, we evaluate combined outcomes from three paediatric neurosurgical units in the use of AIS systems for paediatric patients with hydrocephalus.

Methods

The three units established independent databases with data collected from varying time frames. All procedures, where a complete AIS system or part was implanted into patients from 0–16 years in age, were included. The primary outcome measure was shunt infection rate. Shunt procedures were classified as de novo (DNS) and clean revision (CRS). An infant (<1 year) de novo insertion subgroup was also analyzed. AIS shunts were compared to a historical control of non-AIS shunts and results were analysed by centre using an odds ratio with a 95% confidence interval and combined across centres by meta-analysis.

Results

A total of 581 AIS implantation procedures were performed in all three units. The comparative non-AIS historical cohort comprised of 1,963 procedures. The pooled effect estimate indicated a clinical advantage for AIS shunts compared to non-AIS shunts, odds ratio (OR), 0.60 (95% CI 0.38, 0.93). The de novo infant group comprised 153 AIS systems, and 465 de novo shunts in the historical non-AIS cohort. Again the pooled effect estimate indicated a clinical advantage for AIS shunts compared to non-AIS shunts, OR 0.38 (95% CI, 0.17; 0.85); however, there was a large overlap of confidence intervals in the results from the different sites indicating the uncertainty in the treatment effect estimates. Over 80% of organisms were gram positive in the infected AIS cohort with a median time to infection of 19 days. Two rifampicin-resistant organisms and three MRSA organisms were detected.

Conclusion

Data from this exclusively paediatric multi-centre historical control study suggest that AIS may significantly reduce infection rates in de novo and clean revision shunt implants. Although the possibility of bias cannot be excluded due to study design, this is the largest study on an exclusively paediatric cohort comparing standard shunts to AIS implants. Future double-blinded RCTs are needed to confirm AIS efficacy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Aryan HE, Meltzer HS, Park MS, Bennett RL, Jandial R, Levy ML (2005) Initial experience with antibiotic-impregnated silicone catheters for shunting of cerebrospinal fluid in children. Childs Nerv Syst 21:56–61

    Article  PubMed  Google Scholar 

  2. Bayston R (1989) Hydrocephalus shunt infections. Chapman and Hall, London

    Google Scholar 

  3. Bayston R, Grove N, Siegel J, Lawellin D, Barsham S (1989) Prevention of hydrocephalus shunt catheter colonisation in vitro by impregnation with antimicrobials. J Neurol Neurosurg Psychiatry 52:605–609

    Article  PubMed  CAS  Google Scholar 

  4. Bayston R, Lambert E (1997) Duration of protective activity of cerebrospinal fluid shunt catheters impregnated with antimicrobial agents to prevent bacterial catheter-related infection. J Neurosurg 87:247–251

    Article  PubMed  CAS  Google Scholar 

  5. Bayston R, Ashraf W, Bhundia C (2004) Mode of action of an antimicrobial biomaterial for use in hydrocephalus shunts. J Antimicrob Chemother 53:778–782

    Article  PubMed  CAS  Google Scholar 

  6. Belli A, Thompson DNP, Harkness WFJ, Pitt M, Hayward RD (2001) Shunt infection rates: surgical skill or statistical serendipity? Analysis of 1,106 cases. Br J Neurosurg 15:82, Abstract

    Article  Google Scholar 

  7. Borgbjerg BM, Gjerris F, Albeck MJ, Borgesen SE (1995) Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first time shunts. Acta Neurochir (Wien) 136:1–7

    Article  CAS  Google Scholar 

  8. Choksey MS, Malik IA (2004) Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 75:87–91

    PubMed  CAS  Google Scholar 

  9. Choux M, Genitori L, Lang D, Lena G (1992) Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:875–880

    Article  PubMed  CAS  Google Scholar 

  10. Drake JM, Sainte-Rose C (1995) The shunt book. Blackwell Science, Cambridge, Mass

    Google Scholar 

  11. Enger PO, Svendsen F, Wester K (2003) CSF shunt infections in children: experiences from a population-based study. Acta Neurochir (Wien) 145:243–248

    Article  CAS  Google Scholar 

  12. Eymann R, Chehab S, Strowitzki M, Steudel W-I, Keifer M (2008) Clinical and economic consequences of antibiotic-impregnated cerebrospinal fluid shunt catheters. J Neurosurg Pediatrics 1:444–450

    Article  Google Scholar 

  13. Fan-Havard P, Nahata MC (1987) Treatment and prevention of infections of cerebrospinal fluid shunts. Clin Pharm 6:866–880

    PubMed  CAS  Google Scholar 

  14. Govender ST, Nathoo N, van Dellen JR (2003) Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg 99:831–839

    Article  PubMed  Google Scholar 

  15. Hayhurst C, Cooke R, Williams D, Kandasamy J, O'Brien DF, Mallucci CL (2008) The impact of antibiotic-impregnated catheters on shunt infection in children and neonates. Childs Nerv Syst 24(5):557–562, Epub 2007 Oct 26

    Article  PubMed  Google Scholar 

  16. Kan P, Kestle J (2007) Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst 23:773–777

    Article  PubMed  Google Scholar 

  17. Kulkarni AV, Drake JM, Lamberti-Pasculli M (2001) Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:195–201

    Article  PubMed  CAS  Google Scholar 

  18. Pattavilakom A, Kotasnas D, Korman TM, Xenos C, Danks A (2006) Duration of in vivo antimicrobial activity of antibiotic-impregnated cerebrospinal fluid catheters. Neurosurgery 58:930–935

    Article  PubMed  Google Scholar 

  19. Pattavilakom A, Xenos C, Bradfield O, Danks RA (2007) Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J Clin Neurosci 14(6):526–531

    Article  PubMed  CAS  Google Scholar 

  20. Pople IK, Bayston R, Hayward RD (1992) Infection of cerebrospinal fluid shunts in infants: a study of etiological factors. J Neurosurg 77:29–36

    Article  PubMed  CAS  Google Scholar 

  21. Ratilal B, Costa J, Sampaio C (2008) Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review. J Neurosurg Pediatrics 1:48–56

    Article  Google Scholar 

  22. Ritz R, Roser F, Morgalla M, Dietz K, Tatagiba M, Will BE (2007) Do antibiotic-impregnated shunts in hydrocephalus therapy reduce the risk of infection? An observational study in 258 patients. BMC Infect Dis 8(7):38

    Article  Google Scholar 

  23. Richards HK, Seeley HM, Pickard JD (2009) Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry. J Neurosurg Pediatr 4(4):389–393

    Article  PubMed  Google Scholar 

  24. Ronan A, Hogg GG, Klug GL (1995) Cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J 14:782–786

    Article  PubMed  CAS  Google Scholar 

  25. Schiff SJ, Oakes WJ (1989) Delayed cerebrospinal-fluid shunt infection in children. Pediatr Neurosci 15:131–135

    Article  PubMed  CAS  Google Scholar 

  26. Sciubba DM, Stuart RM, McGirt MJ, Woodworth GF, Samdani A, Carson B, Jallo GI (2005) Effect of antibiotic-impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J Neurosurg 103:131–136

    PubMed  Google Scholar 

  27. Sciubba DM, Lin LM, Woodworth GF, McGirt MJ, Carson B, Jallo GI (2007) Factors contributing to the medical costs of cerebrospinal fluid shunt infection treatment in pediatric patients with standard shunt components compared with those in patients with antibiotic impregnated components. Neurosurg Focus 22(4):E9

    Article  PubMed  Google Scholar 

  28. Sciubba DM, McGirt MJ, Woodworth GF, Carson B, Jallo GI (2007) Prolonged exposure to antibiotic-impregnated shunt catheters does not increase incidence of late shunt infections. Childs Nerv Syst 23:867–871

    Article  PubMed  Google Scholar 

  29. Shapiro S, Boaz J, Kleiman M, Kalsbeck J, Mealey J (1988) Origin of organisms infecting ventricular shunts. Neurosurgery 22:868–872

    Article  PubMed  CAS  Google Scholar 

  30. Taggart DP, D'Amico R, Altman DG (2001) Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet 358(9285):870–875

    Article  PubMed  CAS  Google Scholar 

  31. Thompson DN, Hartley JC, Hayward RD (2007) Shunt infection: is there a near-miss scenario? J Neurosurg 106(1 Suppl):15–19

    PubMed  Google Scholar 

  32. Walters BC, Hoffman HJ, Hendrick EB, Humphreys RP (1984) Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg 60:1014–1021

    Article  PubMed  CAS  Google Scholar 

  33. Wang KW, Chang WN, Shih TY, Huang CR, Tsai NW, Chang CS, Chuang YC, Liliang PC, Su TM, Rau CS, Tsai YD, Cheng BC, Hung PL, Chang CJ, Lu CH (2004) Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis 57:44–48

    PubMed  Google Scholar 

Download references

Conflict of interest

None.

Disclosure

The authors confirm that no financial support has been received for the inception or preparation of this manuscript.

Author information

Authors and Affiliations

  1. Department of Paediatric Neurosurgery, Alder Hey, Royal Liverpool Children’s University Hospital NHS Trust, Liverpool, UK

    Jothy Kandasamy, Caroline Hayhurst & Conor Mallucci

  2. Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery NHS Trust, Liverpool, UK

    Michael D. Jenkinson

  3. Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, UK

    Kerry Dwan

  4. Department of Microbiology, Great Ormond Street Hospital for Children NHS Trust, Bloomsbury, UK

    John C. Hartley

  5. Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, Bloomsbury, UK

    Sylvia Gatscher & Dominic Thompson

  6. Department of Paediatric Neurosurgery, Leeds General Infirmary NHS Trust, Leeds, UK

    Darach Crimmins

Authors
  1. Jothy Kandasamy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kerry Dwan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John C. Hartley
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael D. Jenkinson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Caroline Hayhurst
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sylvia Gatscher
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dominic Thompson
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Darach Crimmins
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Conor Mallucci
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Conor Mallucci.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kandasamy, J., Dwan, K., Hartley, J.C. et al. Antibiotic-impregnated ventriculoperitoneal shunts—a multi-centre British paediatric neurosurgery group (BPNG) study using historical controls. Childs Nerv Syst 27, 575–581 (2011). https://doi.org/10.1007/s00381-010-1290-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00381-010-1290-z

Keywords

Search

Navigation