Top

Child's Nervous System

Published in:

01-11-2007 | Original Paper

Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures

Authors: Benoit J. M. Pirotte, Alphonse Lubansu, Michael Bruneau, Chakir Loqa, Nathalie Van Cutsem, Jacques Brotchi

Published in: Child's Nervous System | Issue 11/2007

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.

Kanev PM, Sheehan JM (2003) Reflections on shunt infection. Pediatr Neurosurg 39:285–290PubMedCrossRef

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 6:43PubMedCrossRef

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 92:31–38PubMed

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):442–446PubMed

Vinchon M, Dhellemmes P (2006) Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:692–697PubMedCrossRef

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 3:106–109PubMedCrossRef

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 21:56–61PubMedCrossRef

Bafeltowska JJ, Buszman E, Mandat KM, Hawranek JK (2004) Therapeutic vancomycin monitoring in children with hydrocephalus during treatment of shunt infections. Surg Neurol 62:142–150PubMedCrossRef

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 105:869–872PubMed

10.

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)

11.

Biyani N, Grisaru-Soen G, Steinbok P, Sgouros S, Constantini S (2006) Prophylactic antibiotics in paediatric shunt surgery. Childs Nerv Syst 22:1465–1471PubMedCrossRef

12.

Brown EM, Edwards RJ, Pople IK (2006) Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery 58:657–665PubMedCrossRef

13.

Choksey MS, Malik IA (2004) Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 5:87–91

14.

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

15.

Davis SE, Levy ML, McComb JG, Masri-Lavine L (1999) Does age or other factors influence the incidence of ventriculoperitoneal shunt infections? Pediatr Neurosurg 30:253–257PubMedCrossRef

16.

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

17.

Kestle JR, Cochrane DD, Drake JM (2006) Shunt insertion in the summer: is it safe? J Neurosurg 105(3 Suppl):165–168PubMed

18.

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):177–181PubMed

19.

Kontny U, Hofling B, Gutjahr P, Voth D, SchwarzM, Schmitt HJ (1993) CSF shunt infections in children. Infection 21:89–92PubMedCrossRef

20.

Kouyialis AT, Stranjalis G, Korfias S, Sakas DE (2006) Long-term air-exposed functioning hydrocephalus valve with no infection. South Med J 99:1127–1129PubMed

21.

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

22.

Lima MM, Pereira CU, Silva AM (2007) Ventriculoperitoneal shunt infections in children and adolescents with hydrocephalus. Arq Neuropsiquiatr 65:118–123PubMed

23.

McAdams RM, Simone S, Grant G, DiGeronimo RJ (2006) Ventricular peritoneal shunt infection resulting from group B streptococcus. Pediatr Crit Care Med 7:586–588PubMedCrossRef

24.

Morissette I, Gourdeau M, Francoeur J (1993) CSF shunt infections: a fifteen-year experience with emphasis on management and outcome. Can J Neurol Sci 20:118–122PubMed

25.

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 77:386–390PubMed

26.

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

27.

Ragel BT, Browd SR, Schmidt RH (2006) Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 105:242–247PubMed

28.

Ratilal B, Costa J, Sampaio C (2006) Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 3:CD005365PubMed

29.

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 13:584–587PubMedCrossRef

30.

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)PubMedCrossRef

31.

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):131–136PubMed

32.

Stamos JK, Kaufman BA, Yogev R (1993) Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:858–862PubMedCrossRef

33.

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 51:16–24PubMedCrossRef

34.

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

35.

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):5–8PubMed

36.

Tumialan LM, Lin F, Gupta SK (2006) Spontaneous bacterial peritonitis causing Serratia marcescens and Proteus mirabilis ventriculoperitoneal shunt infection. Case report. J Neurosurg 105:320–324PubMed

37.

Turgut M, Alabaz D, Erbey F, Kocabas E, Erman T, Alhan E, Aksaray N (2005) Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 41:131–136PubMedCrossRef

38.

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 6:202–206PubMedCrossRef

39.

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–S11PubMedCrossRef

40.

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)PubMedCrossRef

41.

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 23:289–295PubMedCrossRef

42.

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 38:34–40PubMedCrossRef

Title: Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures
Authors: Benoit J. M. Pirotte
Alphonse Lubansu
Michael Bruneau
Chakir Loqa
Nathalie Van Cutsem
Jacques Brotchi
Publication date: 01-11-2007
Publisher: Springer-Verlag
Published in: Child's Nervous System / Issue 11/2007
Print ISSN: 0256-7040
Electronic ISSN: 1433-0350
DOI: https://doi.org/10.1007/s00381-007-0415-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures

Abstract

Objective

Materials and methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Materials and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 11/2007

Abubakr Muhammad Ibn Zakaria Razi, Rhazes (865–925 ad)

Nonfunctioning endocrine tumor arising from intracranial ectopic pancreas associated with congenital brain malformation

The vestibulo-ocular reflex during active head motion in children and adolescents

Adolescent lumbar disc disease: findings and outcome

Cervical meningomyelocele—an institutional experience

Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in a child with traumatic brain swelling