Modalities and accuracy of diagnosis of external ventricular drainage-related infections: a prospective multicentre observational cohort study
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Device infection is a major complication of placement external ventricular drains (EVD). Diagnostic features are often masked by underlying disease or cerebrospinal fluid (CSF) contamination by blood. We aim to assess which diagnostic modalities are applied for EVD-related infection (ERI) diagnosis and evaluate their accuracy.
This observational prospective study included 187 adult patients with an EVD. Modalities of clinical diagnosis of ERI diagnosed by treating physicians on clinical grounds and blood and CSF analysis (clinically diagnosed ERI (CD-ERI)) were assessed prospectively. Additionally, the diagnostic accuracy of clinical and laboratory parameters for the diagnosis of culture proven ERI (CP-ERI) was evaluated, using data of the study patients and including a retrospective cohort of 39 patients with CP-ERI.
Thirty-one CD-ERIs were diagnosed in the prospective cohort. Most physicians used CSF analysis to establish the diagnosis. ROC analysis revealed an AUC of 0.575 (p = 0.0047) for the number of positive SIRS criteria and AUC of 0.5420 (p = 0.11) for the number of pathological neurological signs for diagnosis of CP-ERI. Diagnostic accuracy of laboratory values was AUC 0.596 (p = 0.0006) for serum white blood cell count (WBCC), AUC 0.550 (p = 0.2489) for serum C-reactive protein, AUC 0.644 (p < 0.0001) for CSF WBCC and AUC 0.690 for CSF WBC/red blood cell count ratio (both p < 0.0001). Neither a temporal trend in potential predictors of CP-ERI nor a correlation between clinical diagnosis and proven CSF infection was found.
Clinicians base their diagnosis of ERI mostly on CSF analysis and occurrence of fever, leading to over-diagnosis. The accuracy of the clinical diagnosis is low. Commonly used clinical and laboratory diagnostic criteria have a low sensitivity and specificity for ERI.
KeywordsExternal ventricular device EVD-related infection Diagnosis CSF changes
Area under the curve
Area under the ROC curve
Clinically diagnosed EVD-related infection
Culture-proven EVD-related infection
- CSF WBCC
CSF white blood cell count
Central nervous system
External ventricular drain
Glasgow Coma Score
Glasgow Outcome Score
Intensive care unit
Length of hospital stay
Red blood cell
Red blood cell count
Receiver operating characteristic
Serum C-reactive protein
Serum white blood cell count
Systemic inflammatory response syndrome
Traumatic brain injury
White blood cell
Compliance with ethical standards
The study protocol was reviewed and approved by the relevant institutional review boards (Ethics Committee Bern, Switzerland; the Alfred Health Ethics Committee, Melbourne, Australia; and the Hawkesbury Human Research Ethics Committee, Northern Sydney Central Coast Health, Australia). All procedures were in accordance with the institutional and national research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Due to the observational nature of the study, which only used data obtained during routine care, formal consent is not required.
Conflict of interest
The authors declare that they have no conflict of interest.
Human and animal rights
This article does not contain any studies with animals performed by any of the authors.
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