Abstract
Objective
The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable on a routine basis and allowed the reduction of shunt infections (SI) in children.
Materials and methods
Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation, we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique; limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation; avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children aged <12 months; (3) procedures for shunt revision.
Results
Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful.
Conclusion
These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical staff. This last issue will be evaluated further in the present ongoing protocol.
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References
Kanev PM, Sheehan JM (2003) Reflections on shunt infection. Pediatr Neurosurg 39:285–290
Sacar S, Turgut H, Toprak S, Cirak B, Coskun E, Yilmaz O, Tekin K (2006) A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period. BMC Infect Dis 6:43
Tuli S, Drake J, Lawless J, Wigg M, Lamberti-Pasculli M (2000) Risk factors for repeated cerebrospinal shunt failures in paediatric patients with hydrocephalus. J Neurosurg 92:31–38
Tuli S, Tuli J, Drake J, Spears J (2004) Predictors of death in paediatric patients requiring cerebrospinal fluid shunts. J Neurosurg 100(5 Suppl Paediatrics):442–446
Vinchon M, Dhellemmes P (2006) Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:692–697
Ammirati M, Raimondi AJ (1987) Cerebrospinal fluid shunt infections in children. A study on the relationship between the etiology of hydrocephalus, age at the time of shunt placement, and infection rate. Childs Nerv Syst 3:106–109
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
Bafeltowska JJ, Buszman E, Mandat KM, Hawranek JK (2004) Therapeutic vancomycin monitoring in children with hydrocephalus during treatment of shunt infections. Surg Neurol 62:142–150
Bani A, Telker D, Hassler W, Grundlach M (2006) Minimally invasive implantation of the peritoneal catheter in ventriculoperitoneal shunt placement for hydrocephalus: analysis of data in 151 consecutive adult patients. J Neurosurg 105:869–872
Bayston R, Ashraf W, Barker-Davies R, Tucker E, Clement R, Clayton J, Freeman BJ, Nuradeen B (2006) Biofilm formation by Propionibacterium acnes on biomaterials in vitro and in vivo: impact on diagnosis and treatment. J Biomed Mater Res A 81A:705–709 (Dec 22)
Biyani N, Grisaru-Soen G, Steinbok P, Sgouros S, Constantini S (2006) Prophylactic antibiotics in paediatric shunt surgery. Childs Nerv Syst 22:1465–1471
Brown EM, Edwards RJ, Pople IK (2006) Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery 58:657–665
Choksey MS, Malik IA (2004) Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 5:87–91
Choux M, Genitori L, Lang D, Lena G (1992) Shunt implantation: reducing the incidence of shunt infection. J Neurosurg 77:875–880
Davis SE, Levy ML, McComb JG, Masri-Lavine L (1999) Does age or other factors influence the incidence of ventriculoperitoneal shunt infections? Pediatr Neurosurg 30:253–257
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
Kestle JR, Cochrane DD, Drake JM (2006) Shunt insertion in the summer: is it safe? J Neurosurg 105(3 Suppl):165–168
Kestle JR, Garton HJ, Whitehead WE, Drake JM, Kulkarni AV, Cochrane DD, Muszynski C, Walker ML (2006) Management of shunt infections: a multicenter pilot study. J Neurosurg 105(3 Suppl):177–181
Kontny U, Hofling B, Gutjahr P, Voth D, SchwarzM, Schmitt HJ (1993) CSF shunt infections in children. Infection 21:89–92
Kouyialis AT, Stranjalis G, Korfias S, Sakas DE (2006) Long-term air-exposed functioning hydrocephalus valve with no infection. South Med J 99:1127–1129
Kulkarni AV, Drake JM, Lamberti-Pasculli M (2001) Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 94:195–201
Lima MM, Pereira CU, Silva AM (2007) Ventriculoperitoneal shunt infections in children and adolescents with hydrocephalus. Arq Neuropsiquiatr 65:118–123
McAdams RM, Simone S, Grant G, DiGeronimo RJ (2006) Ventricular peritoneal shunt infection resulting from group B streptococcus. Pediatr Crit Care Med 7:586–588
Morissette I, Gourdeau M, Francoeur J (1993) CSF shunt infections: a fifteen-year experience with emphasis on management and outcome. Can J Neurol Sci 20:118–122
Mwang’ombe NJ, Omulo T (2000) Ventriculoperitoneal shunt surgery and shunt infections in children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi. East Afr Med J 77:386–390
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
Ragel BT, Browd SR, Schmidt RH (2006) Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:242–247
Ratilal B, Costa J, Sampaio C (2006) Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 3:CD005365
Rotim K, Miklic P, Paladino J, Melada A, Marcikic M, Scap M (1997) Reducing the incidence of infection in paediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 13:584–587
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 (Mar 27)
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(2 Suppl):131–136
Stamos JK, Kaufman BA, Yogev R (1993) Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:858–862
Tang H, Wang A, Liang X, Cao T, Salley SO, McAllister JP 3rd, Ng Simon KY (2006) Effect of surface proteins on Staphylococcus epidermidis adhesion and colonization on silicone. Colloids Surf B Biointerfaces 51:16–24
Thompson DN, Hartley JC, Hayward RD (2007) Shunt infection: is there a near-miss scenario? J Neurosurg 106(1 Suppl):15–19
Tulipan N, Cleves MA (2006) Effect of an intraoperative double-gloving strategy on the incidence of cerebrospinal fluid shunt infection. J Neurosurg 104(1 Suppl):5–8
Tumialan LM, Lin F, Gupta SK (2006) Spontaneous bacterial peritonitis causing Serratia marcescens and Proteus mirabilis ventriculoperitoneal shunt infection. Case report. J Neurosurg 105:320–324
Turgut M, Alabaz D, Erbey F, Kocabas E, Erman T, Alhan E, Aksaray N (2005) Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 41:131–136
Bruinsma N, Stobberingh EE, Herpers MJ, Vles JS, Weber BJ, Gavilanes DA (2000) Subcutaneous ventricular catheter reservoir and ventriculoperitoneal drain-related infections in preterm infants and young children. Clin Microbiol Infect 6:202–206
Cochrane DD, Kestle J (2002) Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1989–2001. Eur J Pediatr Surg 12(Suppl 1):S6–S11
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 (Feb 7)
McGirt MJ, Buck DW 2nd, Sciubba D, Woodworth GF, Carson B, Weingart J, Jallo G (2007) Adjustable vs set-pressure valves decrease the risk of proximal shunt obstruction in the treatment of paediatric hydrocephalus. Childs Nerv Syst 23:289–295
McGirt MJ, Wellons JC 3rd, Nimjee SM, Bulsara KR, Fuchs HE, George TM (2003) Comparison of total versus partial revision of initial ventriculoperitoneal shunt failures. Pediatr Neurosurg 38:34–40
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Pirotte, B.J.M., Lubansu, A., Bruneau, M. et al. Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst 23, 1251–1261 (2007). https://doi.org/10.1007/s00381-007-0415-5
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DOI: https://doi.org/10.1007/s00381-007-0415-5