Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. A randomized trial of ceftriaxone versus trimethoprim-sulfamethoxazole to prevent ventriculoperitoneal shunt infection. Healthcare Savings Associated with Reduced Infection Rates Using Antimicrobial Suture Wound Closure for Cerebrospinal Fluid Shunt Procedures A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. Reduction of drain-associated cerebrospinal fluid infections in neurosurgical inpatients: a prospective study. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection. The impact of ventricular catheter impregnated with antimicrobial agents on infections in patients with ventricular catheter: interim report. Shunt surgery in patients with hydrocephalus and white matter changes. Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. CSF antibiotic prophylaxis for neurosurgical patients with ventriculostomy: a randomised study. Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial
OBJECT Implantation of cerebrospinal fluid ( CSF ) shunting devices is associated with a 5 - 15 % risk of infection as cited in contemporary pediatric neurosurgical literature . Shunt infections typically require complete removal of the device and prolonged antibiotic treatment followed by shunt replacement . Moreover , shunt infections are commonly associated with prolonged hospital stays , potential comorbidity , and the increased risk of neurological compromise due to ventriculitis or surgical complications . The authors prospect ively evaluated the incidence of CSF shunt infection following shunt procedures performed using either antimicrobial suture ( AMS ) or conventional suture . METHODS In a single-center , prospect i ve , double-blinded , r and omized controlled trial , the authors enrolled 61 patients , among whom 84 CSF shunt procedures were performed over 21 months . R and omization to the study ( AMS ) or control ( placebo ) group was stratified to minimize the effect of known shunt infection risk factors on the findings . Antibacterial shunt components were not used . The primary outcome measure was the incidence of shunt infection within 6 months of surgery . RESULTS The shunt infection rate in the study group was 2 ( 4.3 % ) of 46 procedures and 8 ( 21 % ) of 38 procedures in the control group ( p = 0.038 ) . There were no statistically significant differences in shunt infection risk factors between the groups ( procedure type and time , age < 6 months , weight < 4 kg , recent history of shunt infection ) . No suture-related adverse events were reported in either group . CONCLUSIONS These results support the suggestion that the use of AMS for CSF shunt surgery wound closure is safe , effective , and may be associated with a reduced risk of postoperative shunt infection . A larger r and omized controlled trial is needed to confirm this association OBJECT Quality improvement techniques are being implemented in many areas of medicine . In an effort to reduce the ventriculoperitoneal shunt infection rate , a st and ardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network ( HCRN ) . METHODS The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained . The protocol was prospect ively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure .  Infections were defined on the basis of CSF , wound , or pseudocyst cultures ; wound breakdown ; abdominal pseudocyst ; or positive blood cultures in the presence of a ventriculoatrial shunt . Procedures and infections were measured before and after protocol implementation . RESULTS Twenty-one surgeons at 4 centers performed 1571 procedures between June 1 , 2007 , and February 28 , 2009 . The minimum follow-up was 6 months . The Network infection rate decreased from 8.8 % prior to the protocol to 5.7 % while using the protocol ( p = 0.0028 , absolute risk reduction 3.15 % , relative risk reduction 36 % ) . Three of 4 centers lowered their infection rate . Shunt surgery after external ventricular drainage ( with or without prior infection ) had the highest infection rate . Overall protocol compliance was 74.5 % and improved over the course of the observation period . Based on logistic regression analysis , the use of  BioGlide catheters  ( odds ratio [ OR ] 1.91 , 95 % CI 1.19 - 3.05 ; p = 0.007 ) and the use of  antiseptic cream by any members of the surgical team ( instead of a formal surgical scrub by all members of the surgical team ; OR 4.53 , 95 % CI 1.43 - 14.41 ; p = 0.01 ) were associated with an increased risk of infection . CONCLUSIONS The st and ardized protocol for shunt surgery significantly reduced shunt infection across the HCRN . Overall protocol compliance was good . The protocol has established a common baseline within the Network , which will facilitate assessment of new treatments . Identification of factors associated with infection will allow further protocol refinement in the future BACKGROUND AND PURPOSE Shunt infection represents a particularly morbid condition , which can also result in mortality . In order to decrease the high morbidity and mortality rates , prevention is an essential step . The purpose of this study was to compare the prophylactic use of ceftriaxone and trimethoprim-sulfamethoxazole ( SXT ) for the prevention of ventriculoperitoneal ( VP ) shunt infection . METHODS In this prospect i ve , single-institution , r and omized clinical trial , 107 children with hydrocephalus and an indication for shunting were r and omly assigned to prophylaxis with ceftriaxone ( n = 50 ) or SXT ( 55 ) , each administered as a single dose during anesthesia and two divided doses postoperatively . Patients were followed up for at least one year . RESULTS The mean age of patients was 15 months , and 85 % were aged 6 months or younger . During the first postoperative year , meningitis occurred in 13.5 % of patients receiving ceftriaxone and 14.5 % of the SXT group , with no statistically significant difference between the groups . Younger age , presence of cerebrospinal fluid leakage and aqueductal stenosis as a cause of hydrocephalus showed significant correlation with meningitis occurrence on univariate analysis . However , only the latter 2 factors were associated with meningitis on multivariate analysis . The risk of shunt infection did not correlate with the gender of the patient , time of VP shunt surgery , or duration of hospitalization for shunting . CONCLUSION Ceftriaxone and SXT showed similar efficacy in preventing shunt infection . Cerebrospinal fluid leakage before or after VP shunt placement and aqueductal stenosis were independent risk factors for meningitis after VP shunt Background / Aims / Methods : This is a follow-up study from a recent r and omized controlled trial conducted at the Women and Children ’s Hospital of Buffalo that investigated the use of antimicrobial sutures ( AMS ) for wound closure during cerebrospinal fluid shunting procedures . Our purpose was to determine the average cost of shunt infections at our institution and estimate the healthcare savings associated with reduced infection rates secondary to AMS use . Result : We found that the treatment and management of a shunt infection result ed in a 5.3-fold increase in hospital charges . Conclusion : The potential healthcare savings associated with reduced infection rates are significant . These calculations demonstrate the profound economic effect a reduction in shunt infection rates may have on a healthcare system BACKGROUND Cerebrospinal fluid ( CSF ) shunts become infected primarily by bacterial organisms indigenous to the patient 's skin flora , but bacteria from the operating room environment , hospital , or no obvious source may also infect a shunt . To decrease the incidence of shunt infection , a no-touch technique protocol was developed and utilized in a prospect i ve manner . METHODS A before-after trial analysis was performed to compare the infection rates between patients who had CSF shunts placed using the no-touch technique protocol versus patients who had surgery without the protocol . Patients were stratified by age , etiology of hydrocephalus , type of shunt surgery , and presence of a contaminated skin wound , namely , tracheostomy , gastrostomy-jejunostomy , colostomy , or halo . The differences in infection rates were analyzed with the Fisher exact test with midpoint value correction , and st and ard statistical methods were used to calculate the 90 % confidence interval odds ratio and number to treat . RESULTS The no-touch technique protocol result ed in a clinical ly significant threefold decrease in shunt infection rate from 9.1 % to 2.9 % ( p = 0.058 at 0.10 level , odds ratio 0.305 , confidence interval 0.084 - 1.11 ) , and a near threefold decrease in the infection rate per patient from 11.3 % to 3.9 % ( p = 0.032 at 0.10 level , odds ratio 0.243 , confidence interval 0.065 - 0.906 ) . CONCLUSIONS The no-touch technique protocol as described herein is a useful method to decrease shunt infection . A larger prospect i ve , r and omized , multicenter clinical trial is encouraged to stringently assess the efficacy of the protocol OBJECTIVE Forty percent of st and ard cerebrospinal fluid shunts implanted for the treatment of pediatric hydrocephalus fail within the first year . Two new shunt valves design ed to limit excess flow , particularly in upright positions , were studied to compare treatment failure rates with those for st and ard differential-pressure valves . METHODS Three hundred-forty-four hydrocephalic children ( age , birth to 18 yr ) undergoing their first cerebrospinal fluid shunt insertion were r and omized at 12 North American or European pediatric neurosurgical centers . Patients received one of three valves , i.e. , a st and ard differential-pressure valve ; a Delta valve ( Medtronic PS Medical , Goleta , CA ) , which contains a siphon-control component design ed to reduce siphoning in upright positions ; or an Orbis-Sigma valve ( Cordis , Miami , FL ) , with a variable-resistance , flow-limiting component . Patients were monitored for a minimum of 1 year . Endpoints were defined as shunt failure result ing from shunt obstruction , overdrainage , loculations of the cerebral ventricles , or infection . Outcome events were assessed by blinded independent case review . RESULTS One hundred-fifty patients reached an endpoint ; shunt obstruction occurred in 108 ( 31.4 % ) , overdrainage in 12 ( 3.5 % ) , loculated ventricles in 2 ( 0.6 % ) , and infection in 28 ( 8.1 % ) . Sixty-one percent were shunt failure-free at 1 year and 47 % at 2 years , with a median shunt failure-free duration of 656 days . There was no difference in shunt failure-free duration among the three valves ( P = 0.24 ) . CONCLUSION Cerebrospinal fluid shunt failure , predominantly from shunt obstruction and infection , remains a persistent problem in pediatric hydrocephalus . Two new valve design s did not significantly affect shunt failure rates Hydrocephalic patients undergo repetitive surgical procedures , most of which involve the scalp . 141  shaveless operations involving scalp incisions for cerebrospinal fluid ( CSF ) shunts as well as 218 historical controls were review ed after the senior author ceased shaving the scalp .  The study population has been followed for a mean of 13.4 months and the control population for a mean of 38.6 months . The actuarial rate of infection at 1 year was 3.3 % in the study population and 6.9 % in the control population . Anesthesia times were not significantly different . Shaving of the scalp is not a critical step in the prevention of CSF shunt infection OBJECTIVE Infection remains the most significant complication of ventriculoperitoneal shunt surgery and the reported rates of cerebrospinal fluid shunt infection vary widely across studies in patients with hydrocephalus . The objective of this study is to review and evaluate the infections complicating ventriculoperitoneal shunt surgery in patients with hydrocephalus . METHODS Patients who underwent ventriculoperitoneal shunt surgery for hydrocephalus between 1961 and 2010 were included . Medical charts , operative reports , imaging studies , and clinical follow-up evaluations were review ed and analyzed retrospectively . RESULTS A total of 1015 patients with hydrocephalus who underwent ventriculoperitoneal shunt surgery were included . The mean and median follow-up was 9.2 and 6.5 years , respectively . The median age of the patients at the time of ventriculoperitoneal shunt placement was 41.6 years . Pediatric patients ( < 17 years ) accounted for 30.0 % of the patients . A total 1224 shunt revisions occurred in 1015 patients . Of the 1224 shunt revisions , 162 were due to infection , which occurred in a total of 107 patients . Single infection episodes occurred in 67 patients ( 6.6 % ) , and multiple infection episodes occurred in 40 patients ( 3.9 % ) . The overall infection rate was 7.2 % per procedure and 10.5 % per patient . The overall infection rate was 9.5 % in pediatric patients and 5.1 % in adult patients per procedure . Gender , age , and etiology of hydrocephalus were significantly associated with shunt infection . Pediatric patients had significantly lower infection-free survival than adults ( 79.9 % vs. 94.4 % , P<0.01 ) . CONCLUSIONS Infection remains the most serious complication of ventriculoperitoneal shunt surgery . The findings of this retrospective study show that gender , age , and etiology of hydrocephalus significantly correlated independently with the incidence of infection . Prospect i ve studies are needed to assess the observed associations between the risk factors and incidence of infection in hydrocephalus patients treated with ventriculoperitoneal shunt surgery BACKGROUND External cerebrospinal fluid ( CSF ) diversion via a drain is associated with a variable risk of associated infections which cause significant morbidity . AIM To establish whether simple interventions can reduce the incidence of such infections at a single centre . METHODS A retrospective review of all patients undergoing an external CSF diversion procedure  was carried out to determine the historical rate of infection . Following an institutional protocol which included st and ards on drain insertion , care , sampling and antibiotic prescribing a prospect i ve study was carried out to observe whether infection rates had changed and which factors continued to predict drain-related infections . FINDINGS Retrospective analysis identified 234 procedures in 159 patients over a two-year period . There were 54 drain-related infections , a rate of 21.5 per 1000 drainage days . Duration of CSF drainage [ odds ratio ( OR ) = 1.15 , P < 0.05 ] and the number of CSF sample s taken per drain ( OR = 5.98 , P < 0.05 ) were independently associated with infection . In the prospect ively gathered phase , 132 procedures were recorded in 107 patients over a one-year period . There were 18 infections , a rate of 13.7 per 1000 drainage days . The only independent prognostic factor was duration of CSF drainage ( OR = 1.20 , P < 0.05 ) . Coagulase-negative staphylococci were the most commonly isolated type of organism in both series . CONCLUSION Ensuring drains are removed promptly as soon as CSF diversion is no longer required may reduce the rate of nosocomial infections in this population despite multiple confounding factors . Institutional guidelines may promote best practice in this regard OBJECT Reported rates of CSF shunt infection vary widely across studies . The study objective was to determine the CSF shunt infection rates after initial shunt placement at multiple US pediatric hospitals . The authors hypothesized that infection rates between hospitals would vary widely even after adjustment for patient , hospital , and surgeon factors . METHODS This retrospective cohort study included children 0 - 18 years of age with uncomplicated initial CSF shunt placement performed between January 1 , 2001 , and December 31 , 2005 , and recorded in the Pediatric Health Information System ( PHIS ) longitudinal administrative data base from 41 children 's hospitals . For each child with 24 months of follow-up , subsequent CSF shunt infections and procedures were determined . RESULTS The PHIS data base included 7071 children with uncomplicated initial CSF shunt placement during this time period . During the 24 months of follow-up , these patients had a total of 825 shunt infections and 4434 subsequent shunt procedures . Overall unadjusted 24-month CSF shunt infection rates were 11.7 % per patient and 7.2 % per procedure . Unadjusted 24-month cumulative incidence rates for each hospital ranged from 4.1 to 20.5 % per patient and 2.5 - 12.3 % per procedure . Factors significantly associated with infection ( p < 0.05 ) included young age , female sex , African-American race , public insurance , etiology of intraventricular hemorrhage , respiratory complex chronic condition , subsequent revision procedures , hospital volume , and surgeon case volume . Malignant lesions and trauma as etiologies were protective . Infection rates for each hospital adjusted for these factors decreased to 8.8 - 12.8 % per patient and 1.4 - 5.3 % per procedure . CONCLUSIONS Infections developed in > 11 % of children who underwent uncomplicated initial CSF shunt placements within 24 months . Patient , hospital , and surgeon factors contributed somewhat to the wide variation in CSF shunt infection rates across hospitals . Additional factors may contribute to variation in CSF shunt infection rates between centers , but further study is needed . Benchmarking and future prospect i ve multicenter studies of CSF shunt infection will need to incorporate these and other patient , hospital , and surgeon factors BACKGROUND A double-blind r and omised control study was conducted on all patients who were admitted or referred to the Department of Neurosurgery , Sultanah Aminah Hospital , Johor Bahru , with a diagnosis of hydrocephalus where a ventriculoperitoneal shunt was indicated . METHODS The period of study was from November 2005 to May 2007 , and the follow-up period was 3 months after surgery . R and omisation was carried out in the operating room prior to the procedure . The scrub nurse selected a sealed envelope , which contained the assignment of each patient to 1 of 2 treatment groups : Group 1 patients were treated with topical methicillin , and Group 2 patients were not treated with topical methicillin . Prophylactic antibiotic , cefuroxime ( 25 mg/kg ) was given intravenously at induction . St and ard sterile operative technique was followed in preparing and draping the patients . RESULTS A total of 90 patients were recruited in the study , and 13 ( 14.4 % ) patients developed an infection within 3 months post-operation . Group 1 had a 8.9 % risk of infection , and Group 2 had a 20 % risk ; however , there was no statistically significant post-operative ventriculoperitoneal shunt ( VPS ) infection reduction with the use of topical methicillin in VPS surgery ( P = 0.230 ) . Multivariate analysis showed that only duration of surgery had a significant influence on the incidence of post-operative VPS infection in the non-methicillin group ( P = 0.02 ) . The non-methicillin group had an 8 times greater risk of developing post-operative VPS infection than the methicillin group if surgery lasted longer than 1 hour . CONCLUSION Topical methicillin had no significance in the reduction of post-operative VPS infection INTRODUCTION Previous prospect i ve study in our unit had shown that the use of dual antibiotic prophylaxis in patients with external ventricular drain was associated with decreased incidence of cerebrospinal fluid infection but complicated with opportunistic extracranial infection . In recent years , cerebrospinal fluid shunt catheters impregnated with antimicrobial agents have become available . Theoretically , these catheters provide antibiotic prophylaxis locally without the associated complications of systemic opportunistic infection . METHODS We carried out a prospect i ve r and omized , controlled clinical trial in a regional neurosurgical center in Hong Kong . We recruited patients admitted for emergency neurosurgical operation after informed consent was obtained from next-of-kin . Eligible patients were r and omized to receive an antibiotic-impregnated ventricular catheter or plain ventricular catheter Dual prophylactic antibiotic coverage was given to the patients r and omized for plain ventricular catheter only . Patients who received antibiotic impregnanted catheters were not treated with systematic prophylactic antibiotics . Here we present the analysis of 110 patients , recruited over a 2-year period , to receive antibiotic-impregnanted ventricular catheters versus non-impregnated ventricular cathethers with prophylactic antibiotic coverage . FINDINGS Fifty-two patients were r and omized to antibiotic-impregnated ventricular catheter with no systemic antibiotic prophylaxis ( Group A ) and 58 patients were r and omized to plain ventricular catheters with prophylactic dual antibiotics ( Group B ) . There was no ventriculostomy-related infection in either groups of patients . There was also no statistical significant difference in incidences of extracranial infections between the two groups , p = 0.617 . CONCLUSIONS In this analysis , antibiotic-impregnation of ventricular catheters was as effective as systemic antibiotics in the prevention of ventriculostomy infections , with the potential advantage of avoiding the systemic side-effects of prophylactic antibiotics OBJECT Patients with idiopathic normal pressure hydrocephalus ( iNPH ) often present with impaired  gait  and cognition  together with ventricular enlargement and normal intracranial pressure . Many have vascular risk factors as well as periventricular and deep white matter changes on MR imaging . Abnormal CSF dynamics , that is , high resistance to outflow or improvement after CSF drainage , indicate good effects of shunt surgery . The authors examined whether the worst-case iNPH patients with extensive vascular white matter disease and normal CSF dynamics would benefit from shunt surgery . These patients also fulfilled the criteria for Binswanger disease . Therefore , a r and omized controlled double-blind study was performed . METHODS Fourteen consecutive patients fulfilling the above criteria were r and omized to receive either open or closed shunts . At 3 months after surgery , the patients with initially ligated shunts had their shunts opened . Clinical evaluation consisting of 7 quantitative psychometric and 6 continuous gait tests was performed preoperatively and 3 and 6 months after surgery . RESULTS Patients r and omized to receive open shunts had improved motor ( 30 % increase ) and psychometric ( 23 % increase ) scores 3 months after shunt placement . There were no significant changes between the 3- and 6-month follow-up in these same patients . Conversely , those with initially ligated shunts were unchanged during the first 3-month period , although they improved in both motor ( 28 % ) and cognitive ( 18 % ) functions following removal of the ligature . CONCLUSIONS Patients with enlarged ventricles , hydrocephalic symptoms , and extensive vascular white matter changes benefit from shunt surgery Background : It is controversial whether regular changes of external ventricular drains can reduce cerebrospinal fluid ( CSF ) infection . Objective : To carry out a r and omised controlled clinical trial over a two year period to determine whether a regular change of ventricular catheter every five days could reduce CSF infection and improve outcome . Methods : 103 patients requiring external ventricular drains for more than five days and with no evidence of concurrent CSF infection were studied . The patients were r and omised to regular change of ventricular catheter ( every five days ) and no change unless clinical ly indicated . Results : The CSF infection rates were 7.8 % for the catheter change group and 3.8 % for the no change group , respectively ( rate ratio = 1.80 , 95 % confidence interval 0.33 to 9.81 , p = 0.50 ) . No significant difference was found in intensive care unit stay , ward stay , or clinical outcome between the two groups . Conclusions : Regular changes of ventricular catheter at five day intervals did not reduce the risk of CSF infection . A single external ventricular drain can be employed for as long as clinical ly indicated OBJECT Cerebral vasospasm after subarachnoid hemorrhage ( SAH ) continues to be a major source of morbidity in patients despite significant clinical and basic science research . Efforts to prevent vasospasm by removing spasmogens from the subarachnoid space have produced mixed results . The authors hypothesize that lumbar cisternal drainage can remove blood from the basal subarachnoid spaces more effectively than an external ventricular drain ( EVD ) . This non-r and omized , controlled-cohort study was undertaken to evaluate the effectiveness of a lumbar drain in patients with SAH compared with those in whom an EVD or no form of cerebrospinal fluid ( CSF ) drainage was used to prevent the development of clinical vasospasm and its sequelae . METHODS The authors collected data on 266 patients with nontraumatic SAH who were admitted to the University of Utah Health Sciences Center between January 1994 and January 2003 . Of these , 167 met the study entry criteria . The treatment group consisted of 81 patients in whom a lumbar drain had been placed for CSF shunting  , whereas the control group was composed of 86 patients who received no form of CSF drainage or who were treated solely with an EVD .  Primary outcome measures were as follows : 1 ) clinical ly evident vasospasm ; 2 ) the need for endovascular intervention ; 3 ) vasospasm-induced infa rct ion ; 4 ) disposition at time of discharge ; and 5 ) Glasgow Outcome Scale ( GOS ) score at 1 to 3 months postdischarge . Secondary outcomes included length of stay and the need for CSF shunting . The presence of a lumbar drain conferred a statistically significant protective and beneficial effect across all outcome measures , reducing the incidence of clinical vasospasm from 51 to 17 % , the need for angioplasty from 45 to 17 % , and the occurrence of vasospastic infa rct ion from 27 to 7 % ( all p < or = 0.001 - 0.008 ) . Patients in the treatment group were more likely to be discharged home ( 54 % compared with 25 % , p = 0.002 ) and to have a GOS score of 5 at follow up ( 71 % compared with 35 % , p < 0.001 ) . The mean number of days spent in the intensive care unit and in the hospital overall was also fewer in the treatment group . A similar degree of benefit was found in patients with different Fisher grade s and regardless of whether an EVD was needed on presentation , both by subgroup analysis and multivariate logistic regression modeling . There was no statistical difference between the groups in terms of patients requiring a shunt . Complications with lumbar drains were rare and yielded no permanent sequelae . CONCLUSIONS Shunting of CSF through a lumbar drain after an SAH markedly reduces the risk of clinical ly evident vasospasm and its sequelae , shortens hospital stay , and improves outcome . Its beneficial effects are probably mediated through the removal of spasmogens that exist in the CSF . The results of this study warrant a r and omized clinical trial , which is currently under way The value of prophylactic antibiotics for patients with ventricular catheter for monitoring and CSF drainage is uncertain . 228 patients were r and omised to receive perioperative antibiotics only ( Unasyn , Group I ) or prolonged antibiotics for the presence of the ventricular catheter ( Unasyn and Aztreonam , Group II ) . The incidence of intracranial and extracranial infection was documented prospect ively . Group II patients had a significantly reduced incidence of CSF infection [ 3/115 ( 3 % ) vs 12/113 ( 11 % ) , p = 0.01 ] and extracranial infections [ 23/115 ( 20 % ) vs 48/113 ( 42 % ) , p = 0.002 ] . CSF pathogens in Group II patients were MRSA and C and ida , whereas in Group I , Staphylococci , E coli and Klebsiella . Although prolonged antibiotic prophylaxis significantly reduced the incidence of serious CSF infection as well as extracranial infections , this policy did select resistant or opportunistic pathogens such as C and ida and MRSA Background Hydrocephalus ( HC ) after aneurysmal subarachnoid hemorrhage ( aSAH ) is a common sequel . Proper selection of patients in need of permanent cerebrospinal fluid ( CSF ) diversion is , however , not straightforward . The aim of this study was to identify predictors of CSF shunt dependency following aSAH . Methods We re-analyzed data acquired from aSAH patients previously enrolled in a prospect i ve , controlled single-center clinical trial in which shunt dependency was not one of the end points . In the present study patients were allocated into two groups : those receiving a shunt ( here denoted as shunt dependent ) and those not receiving a shunt , based on a clinical decision process . Predictors of shunt dependency were identified by applying uni- and multivariable analysis . We tested a set of predefined possible risk factors based on the results of the clinical trial , including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus . Results Ninety patients were included in the study . Significant predictors of shunt dependency were poor clinical grade at admission [ odds ratio ( OR ) 4.7 , 95 % confidence interval ( CI ) 1.2–18.4 ] , large amounts of subarachnoid blood ( OR 3.8 , 95 % CI 1.0–14.0 ) , large ventricular size on preoperative cerebral computer tomographic ( CT ) scans ( OR 1.0 , 95 % CI 1.0–1.1 ) , and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus ( OR 16.3 , 95 % CI 4.0–67.1 ) . Age ≥70 years , larger amounts of intraventricular blood , vertebrobasilar aneurysm , and endovascular treatment tended to increase the likelihood of receiving a shunt . Outcome was not significantly different between shunted and non-shunted patients . Conclusions In this cohort of patients with clinical grade aSAH at admission , larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT , and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency . Shunt dependency did not hamper outcome
Only antibiotic-impregnated suture , a no-shave policy , and double gloving with glove change prior to shunt h and ling , were associated with a significant reduction in shunt infection .
In a hospital with high methicillin-resistant staphylococcus aureus ( MRSA ) prevalence , a r and omized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates .
Conclusion Despite wide variation in compliance rates , the implementation of comprehensive surgical protocol s reduced shunt infection in all published studies .
Antibiotic-impregnated suture , a no-shave policy , double gloving with glove change prior to device manipulation , and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection
Purpose Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost .
We conducted a systematic review of the current evidence of comprehensive surgical protocol s or individual interventions design ed to reduce shunt infection incidence .