Acta Neurochirurgica

, Volume 160, Issue 10, pp 2039–2047 | Cite as

Modalities and accuracy of diagnosis of external ventricular drainage-related infections: a prospective multicentre observational cohort study

  • J. Berger-Estilita
  • M. Passer
  • M. Giles
  • J. Wiegand
  • Tobias M. MerzEmail author
Original Article - Neurosurgical intensive care
Part of the following topical collections:
  1. Neurosurgical intensive care



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.


External 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 white blood cell count


Central nervous system


Coagulase-negative staphylococci


C-reactive protein


Cerebrospinal fluid


EVD-related infection


External ventricular drain


Glasgow Coma Score


Glasgow Outcome Score


Intracerebral haemorrhage


Intracerebral pressure


Intensive care unit


Length of hospital stay


Polymorphonuclear neutrophils


Red blood cell


Red blood cell count


Receiver operating characteristic


Serum C-reactive protein


Serum white blood cell count


Subarachnoid haemorrhage


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.


  1. 1.
    Arabi Y, Memish ZA, Balkhy HH, Francis C, Ferayan A, Al Shimemeri A, Almuneef MA (2005) Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control 33:137–143CrossRefPubMedGoogle Scholar
  2. 2.
    Beer R, Lackner P, Pfausler B, Schmutzhard E (2008) Nosocomial ventriculitis and meningitis in neurocritical care patients. J Neurol 255:1617–1624. CrossRefPubMedGoogle Scholar
  3. 3.
    Berger C, Schwarz S, Schaebitz WR, Aschoff A, Schwab S (2002) Serum procalcitonin in cerebral ventriculitis. Crit Care Med 30:1778–1781CrossRefPubMedGoogle Scholar
  4. 4.
    Bogdahn U, Lau W, Hassel W, Gunreben G, Mertens HG, Brawanski A (1992) Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus—evaluation of risk factors. Neurosurgery 31:898–903 discussion 903-894CrossRefPubMedGoogle Scholar
  5. 5.
    Bota DP, Lefranc F, Vilallobos HR, Brimioulle S, Vincent JL (2005) Ventriculostomy-related infections in critically ill patients: a 6-year experience. J Neurosurg 103:468–472CrossRefPubMedGoogle Scholar
  6. 6.
    Cinibulak Z, Aschoff A, Apedjinou A, Kaminsky J, Trost HA, Krauss JK (2016) Current practice of external ventricular drainage: a survey among neurosurgical departments in Germany. Acta Neurochir 158:847–853. CrossRefPubMedGoogle Scholar
  7. 7.
    Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A (2008) Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis 47:73–82. CrossRefPubMedGoogle Scholar
  8. 8.
    Dettenkofer M, Ebner W, Els T, Babikir R, Lucking C, Pelz K, Ruden H, Daschner F (2001) Surveillance of nosocomial infections in a neurology intensive care unit. J Neurol 248:959–964CrossRefPubMedGoogle Scholar
  9. 9.
    Dey M, Jaffe J, Stadnik A, Awad IA (2012) External ventricular drainage for intraventricular hemorrhage. Curr Neurol Neurosci Rep 12:24–33. CrossRefPubMedGoogle Scholar
  10. 10.
    Edwards NC, Engelhart L, Casamento EM, McGirt MJ (2015) Cost-consequence analysis of antibiotic-impregnated shunts and external ventricular drains in hydrocephalus. J Neurosurg 122:139–147. CrossRefPubMedGoogle Scholar
  11. 11.
    Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9CrossRefPubMedGoogle Scholar
  12. 12.
    Fried HI, Nathan BR, Rowe AS, Zabramski JM, Andaluz N, Bhimraj A, Guanci MM, Seder DB, Singh JM (2016) The insertion and management of external ventricular drains: an evidence-based consensus statement: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care 24:61–81. CrossRefPubMedGoogle Scholar
  13. 13.
    Gordon M, Ramirez P, Soriano A, Palomo M, Lopez-Ferraz C, Villarreal E, Meseguer S, Gomez MD, Folgado C, Bonastre J (2014) Diagnosing external ventricular drain-related ventriculitis by means of local inflammatory response: soluble triggering receptor expressed on myeloid cells-1. Crit Care 18:567. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Grille P, Verga F, Biestro A (2017) Diagnosis of ventriculostomy-related infection: is cerebrospinal fluid lactate measurement a useful tool? J Clin Neurosci 45:243–247. CrossRefPubMedGoogle Scholar
  15. 15.
    Gutierrez-Gonzalez R, Boto GR, Perez-Zamarron A (2012) Cerebrospinal fluid diversion devices and infection. A comprehensive review. Eur J Clin Microbiol Infect Dis 31:889–897. CrossRefPubMedGoogle Scholar
  16. 16.
    Hagel S, Bruns T, Pletz MW, Engel C, Kalff R, Ewald C (2014) External ventricular drain infections: risk factors and outcome. Interdiscip Perspect Infect Dis 2014:708531. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC (2001) The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:891–897CrossRefPubMedGoogle Scholar
  18. 18.
    Hoefnagel D, Dammers R, Ter Laak-Poort MP, Avezaat CJ (2008) Risk factors for infections related to external ventricular drainage. Acta Neurochir 150:209–214; discussion 214. CrossRefPubMedGoogle Scholar
  19. 19.
    Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:309–332. CrossRefPubMedGoogle Scholar
  20. 20.
    Humphreys H, Jenks PJ (2015) Surveillance and management of ventriculitis following neurosurgery. J Hosp Infect 89:281–286. CrossRefPubMedGoogle Scholar
  21. 21.
    Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20. CrossRefPubMedGoogle Scholar
  22. 22.
    Kirmani AR, Sarmast AH, Bhat AR (2015) Role of external ventricular drainage in the management of intraventricular hemorrhage; its complications and management. Surg Neurol Int 6:188. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kitchen WJ, Singh N, Hulme S, Galea J, Patel HC, King AT (2011) External ventricular drain infection: improved technique can reduce infection rates. Br J Neurosurg 25:632–635. CrossRefPubMedGoogle Scholar
  24. 24.
    Konstantelias AA, Vardakas KZ, Polyzos KA, Tansarli GS, Falagas ME (2015) Antimicrobial-impregnated and -coated shunt catheters for prevention of infections in patients with hydrocephalus: a systematic review and meta-analysis. J Neurosurg 122:1096–1112. CrossRefPubMedGoogle Scholar
  25. 25.
    Kubilay Z, Amini S, Fauerbach LL, Archibald L, Friedman WA, Layon AJ (2013) Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution. J Neurosurg 118:514–520. CrossRefPubMedGoogle Scholar
  26. 26.
    Kulkarni AV, Drake JM, Lamberti-Pasculli M (2001) Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:195–201. CrossRefPubMedGoogle Scholar
  27. 27.
    Leverstein-van Hall MA, Hopmans TE, van der Sprenkel JW, Blok HE, van der Mark WA, Hanlo PW, Bonten MJ (2010) A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. J Neurosurg 112:345–353. CrossRefPubMedGoogle Scholar
  28. 28.
    Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr (2002) Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 51:170–181 discussion 181-172CrossRefPubMedGoogle Scholar
  29. 29.
    Mayhall CG, Archer NH, Lamb VA, Spadora AC, Baggett JW, Ward JD, Narayan RK (1984) Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 310:553–559. CrossRefPubMedGoogle Scholar
  30. 30.
    Mounier R, Lobo D, Cook F, Fratani A, Attias A, Martin M, Chedevergne K, Bardon J, Tazi S, Nebbad B, Bloc S, Plaud B, Dhonneur G (2015) Clinical, biological, and microbiological pattern associated with ventriculostomy-related infection: a retrospective longitudinal study. Acta Neurochir 157:2209–2217; discussion 2217. CrossRefPubMedGoogle Scholar
  31. 31.
    Neuman MI, Tolford S, Harper MB (2008) Test characteristics and interpretation of cerebrospinal fluid gram stain in children. Pediatr Infect Dis J 27:309–313. CrossRefPubMedGoogle Scholar
  32. 32.
    Pfisterer W, Muhlbauer M, Czech T, Reinprecht A (2003) Early diagnosis of external ventricular drainage infection: results of a prospective study. J Neurol Neurosurg Psychiatry 74:929–932CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    The Sanford Guide to Antimicrobial Therapy 2017 (2017) 41st. edn. Antimicrobial Therapy, Inc., DallasGoogle Scholar
  34. 34.
    Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Michael Scheld W, van de Beek D, Bleck TP, Garton HJ, Zunt JR (2017) 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventriculitis and meningitis. Clin Infect Dis.
  35. 35.
    van de Beek D, Drake JM, Tunkel AR (2010) Nosocomial bacterial meningitis. N Engl J Med 362:146–154. CrossRefPubMedGoogle Scholar
  36. 36.
    Viallon A, Desseigne N, Marjollet O, Birynczyk A, Belin M, Guyomarch S, Borg J, Pozetto B, Bertrand JC, Zeni F (2011) Meningitis in adult patients with a negative direct cerebrospinal fluid examination: value of cytochemical markers for differential diagnosis. Crit Care 15:R136. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Wiegand J, Hickson L, Merz TM (2016) Indicators of external ventricular drainage-related infections—a retrospective observational study. Acta Neurochir 158:595–601; discussion 601. CrossRefPubMedGoogle Scholar
  38. 38.
    Wyler AR, Kelly WA (1972) Use of antibiotics with external ventriculostomies. J Neurosurg 37:185–187. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  • J. Berger-Estilita
    • 1
  • M. Passer
    • 2
  • M. Giles
    • 2
  • J. Wiegand
    • 3
  • Tobias M. Merz
    • 4
    Email author
  1. 1.Department of Anaesthesiology and Pain Therapy, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
  2. 2.Department of Intensive Care Medicine, Royal North Shore HospitalUniversity of SydneySydneyAustralia
  3. 3.Intensive Care UnitLindenhofspitalBernSwitzerland
  4. 4.Department of Intensive Care Medicine, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland

Personalised recommendations