Healthcare Savings Associated with Reduced Infection Rates Using Antimicrobial Suture Wound Closure for Cerebrospinal Fluid Shunt Procedures A randomized trial of ceftriaxone versus trimethoprim-sulfamethoxazole to prevent ventriculoperitoneal shunt infection. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. 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 no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Vancomycin versus cefazolin prophylaxis for cerebrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. 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. The Efficacy and Cost of Prophylactic and Periprocedural Antibiotics in Patients with External Ventricular Drains Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. Ventriculoperitoneal shunt of continuous flow vs valvular shunt for treatment of hydrocephalus in adults. Risk factors for neurosurgical site infections: an 18-month prospective survey. The impact of ventricular catheter impregnated with antimicrobial agents on infections in patients with ventricular catheter: interim report. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. Efficacy of intraoperative irrigation with saline for preventing shunt infection. Reduction of drain-associated cerebrospinal fluid infections in neurosurgical inpatients: a prospective study. Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial. Prophylactic indomethacin therapy for patent ductus arteriosus in very-low-birth-weight infants. Perioperative risk factors for short term shunt revisions in adult hydrocephalus patients An international registry of systematic-review protocols Continuous CSF drainage in AD Predictors of Shunt-Dependent Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage.
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 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 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 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 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 International guidelines suggest that a high prevalence of meticillin-resistant Staphylococcus aureus ( MRSA ) infections should influence the use of vancomycin for surgical prophylaxis . In order to compare the efficacy and adverse effects of vancomycin versus cefazolin as antimicrobial prophylaxis for insertion of cerebrospinal fluid ( CSF ) shunts , a r and omised prospect i ve clinical trial was performed . Over a 16-month period , all consecutive adult patients who underwent CSF shunt insertion at a university hospital with a high prevalence of MRSA infections were included . Patients were r and omly allocated to receive either vancomycin or cefazolin before surgery and followed-up for four weeks for the development of infections . Of the 176 patients included in the study , 88 received vancomycin and 88 cefazolin .  Shunt infections were significantly less likely to be observed in patients who were on vancomycin prophylaxis ( 4 % vs 14 % ; P=0.03 ) . All isolated staphylococci were resistant to meticillin . Mortality of patients with post-surgical infections was higher in the cefazolin group ( P=0.02 ) . Our data suggest that use of vancomycin as prophylactic agent for cerebrospinal shunt placement reduces the rate of shunt infections in the context of high prevalence of MRSA 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 OBJECTIVE Prophylactic antibiotics are routinely administered to patients with external ventricular drains ( EVDs ) ; however , no conclusive evidence supports this practice . This study compared the efficacy and cost of prophylactic and periprocedural antibiotics in patients with EVDs . METHODS We review ed the charts of 308 patients who had an EVD in place for 3 or more days between January 1996 and June 1997 . Patients with EVDs placed for shunt infections or meningitis were excluded . A st and ard protocol was used to insert and monitor EVDs . Catheters were left in place as long as clinical ly indicated and changed only if they malfunctioned . Cerebrospinal fluid cultures were obtained twice weekly . Prophylactic antibiotics were used at the discretion of the attending neurosurgeon . Patients were divided into two groups : Group A comprised 209 patients who received prophylactic antibiotics  for the duration of the EVD ( intravenously administered cefuroxime , 1.5 g every 8 h ) ; Group B comprised 99 patients who received only periprocedural antibiotics ( intravenously administered cefuroxime  , 1.5 g every 8 h , three  or  less doses ) . RESULTS Although there were significantly more males in Group A than in Group B , the two groups were otherwise well matched , with no significant differences in age , indications , or duration of EVD placement . The overall rate of ventriculitis was 3.9 % . The infection rates for Group A ( 3.8 % ) and Group B ( 4.0 % ) were almost identical . CONCLUSION Prophylactic antibiotics did not significantly reduce the rate of ventriculitis in patients with EVDs , and they may select for resistant organisms . Discontinuing the use of prophylactic antibiotics for EVDs at the authors ’ institution would save approximately $ 80,000 per year in direct drug costs 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 Shunting for hydrocephalus is the neurosurgical procedure most frequently associated with long-term complications . We developed an alternative to valvular shunts based on a simple shunt procedure whose functioning depends on a peritoneal catheter with a highly precise cross-sectional internal diameter of 0.51 mm . Preliminary studies have shown that the shunt of continuous flow ( SCF ) is superior to valvular shunts for the treatment of hydrocephalus in adults . Here , we show the long-term performance of the SCF in adult patients with hydrocephalus secondary to a comprehensive variety of neurological disorders . METHODS In a 5-year period , ventriculoperitoneal shunting was performed on 307 patients with hydrocephalus ; 114 of them were treated with the SCF and 193 controls were treated with a conventional valvular shunt .  Patients were followed from 1 to 5 years after surgery ; endpoint observation was considered at surgical reintervention because of shunt failure . RESULTS At the end of the observation period ( 44 + /- 17 months ) , the failure rate of the shunting device was 14 % for the SCF and 46 % for controls ( P < .0002 ) . Shunt endurance was 88 % in patients with SCF and 60 % in controls . Along the study , signs of overdrainage developed in 40 % of patients treated with valvular shunt , but they were not observed in patients with SCF . CONCLUSIONS The design of the SCF was calculated according to the mean rates of cerebrospinal fluid production ; it takes simultaneous advantage of the intraventricular pressure and the siphon effect and complies with the principle of uninterrupted flow , maintaining a fair equilibrium that prevents under- and overdrainage . The SCF is a simple , inexpensive , and effective treatment for hydrocephalus in adults OBJECT The purpose of this study was to determine the incidence rate and risk factors of surgical site infections ( SSIs ) in neurosurgery for any type of surgery and any American Society of Anesthesiologists class . METHODS The authors undertook an exhaustive 18-month prospect i ve survey including patients who underwent neurosurgery .  In particular , a 30-day follow-up was completed in patients whose surgery did not involve placement of a prosthesis or implant , and 1-year follow-up was completed for patients who underwent surgery to place a prosthesis or implant . The Centers for Disease Control definition of SSI was used . Univariate and multivariate analyses were conducted ; all dependent variables found in univariate analysis were entered in the multiple regression model . A stepwise multiple logistic regression method was used . RESULTS Of the 844 patients studied , 35 SSIs were diagnosed , yielding an incidence rate of 4.1 % ( 95 % confidence interval 3.6 - 4.5 ) . Independent predictive risk factors for infection were cerebrospinal fluid leakage , external shunt , Altemeier class , and further neurosurgery . A lack of antibiotic prophylaxis was not found to be a risk factor . CONCLUSIONS Infection risk factors occur mainly during the postoperative period 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 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 OBJECT The rate of infection following shunt procedures is unacceptably high . The authors have hypothesized that the key to reducing the shunt infection rate is in reducing bacteria in the operating field and wound . This hypothesis has been tested in a prospect i ve nonr and omized controlled manner . METHODS Data obtained in all patients undergoing shunt insertions or revisions for hydrocephalus performed between October 1 , 2003 , and June 12 , 2009 , were review ed . Starting in August 2006 , we began routinely irrigating the operating field and wound with saline solution from a syringe . Prior to this , we had not used any irrigation techniques , providing an adequate control group ( Group A ) for the effect of the irrigation technique . Prior to November 2007 , we used saline containing amikacin for irrigation ( Group B ) . After that date , we used saline only for irrigation ( Group C ) . RESULTS A total of 150 shunt procedures were performed in 79 girls and 71 boys during the study period . The mean age of all patients was 44.0 + /- 59.1 months . Groups A , B , and C comprised 61 , 40 , and 49 shunt procedures , respectively . There was no statistical difference in age among the 3 groups . Nine infections occurred within 90 days in the postoperative period . The overall infection rate was 6.0 % . Eight infections occurred before introducing the irrigation procedure ( infection rate 13.1 % ) . One infection was noted after introducing irrigation ( Group B [ 0.0 % ] + Group C [ 2.0 % ] ; combined B and C infection rate = 1.1 % ) . There was a statistical difference in the infection rate between Group A and Groups B and C combined ( p = 0.003 ) , Groups A and B ( p = 0.021 ) , and Groups A and C ( p = 0.035 ) . In contrast , no statistical difference was observed between Groups B and C ( p > 0.99 ) . Six of the 9 infections were due to staphylococcal species . CONCLUSIONS An irrigation technique used to reduce bacteria in the operating field and wound is effective for preventing shunt infection .  Irrigation alone , and not antibiotics , contributed to the prophylaxis of shunt infection 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 BACKGROUND & AIMS Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts ( TIPS ) . This prospect i ve r and omized trial tested the hypothesis that patients receiving distal splenorenal shunts ( DSRS )  would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding . METHODS A prospect i ve r and omized controlled clinical trial at 5 centers was conducted . One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were r and omized to DSRS or TIPS .  Protocol and event follow-up for 2 - 8 years ( mean , 46 + /- 26 months ) for primary end points of variceal bleeding and encephalopathy and secondary end points of death , ascites , thrombosis and stenosis , liver function , need for transplant , quality of life , and cost were evaluated . RESULTS There was no significant difference in rebleeding ( DSRS , 5.5 % ; TIPS , 10.5 % ; P = .29 ) or first encephalopathy event ( DSRS , 50 % ; TIPS , 50 % ) . Survival at 2 and 5 years ( DSRS , 81 % and 62 % ; TIPS , 88 % and 61 % , respectively ) were not significantly different ( P = .87 ) . Thrombosis , stenosis , and reintervention rates ( DSRS , 11 % ; TIPS , 82 % ) were significantly ( P < .001 ) higher in the TIPS group . Ascites , need for transplant , quality of life , and costs were not significantly different . CONCLUSIONS DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients . Reintervention is significantly greater for TIPS compared with DSRS . Because both procedures have equivalent outcomes , the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed We performed a double-blind , controlled study of prophylactic indomethacin therapy in 47 premature infants ( less than 1700 g ) who had sub clinical patent ductus arteriosus . They received either indomethacin or placebo at a mean age of 2.9 days . Among the 25 infants weighing more than 1000 g , a hemodynamically important ductus shunt developed in only four of the 14 given placebo . The incidence of important shunts , the number of surgical ligations , and the duration of oxygen therapy were not appreciably different between the study groups . In contrast , among the 22 infants who weighed 1000 g or less , a major ductus shunt developed in 10 of the 12 given placebo . In the smaller infants indomethacin therapy was associated with a significantly lower incidence of major shunts , fewer surgical ligations , a decreased duration of oxygen therapy , and fewer days necessary to regain birth weight . We conclude that prophylactic indomethacin therapy in infants weighing under 1000 g prevents the later development of large ductus shunts and decreases morbidity Objectives : The aim of this study was to prospect ively study perioperative variables associated with revision after shunt surgery  for adult hydrocephalus . Methods : Two protocol s were design ed to prospect ively study perioperative risk factors during shunt insertion .  Over 10 years ( 1995–2004 ) , 450 adult ( age > 16 years ) patients with first time shunt implantations were studied . Patients who had been treated with endoscopic third ventriculostomy were excluded from the study . All shunts were design ated as meeting one of two end points : ( 1 ) shunt failure requiring revision within 6 months or ( 2 ) no shunt failure within 6 months .  Shunt revision  within 6 months postoperatively was considered to be related to the shunting procedure . Results : 85 shunt revisions were performed within 6 months after insertion . During the study period the revision rate declined from 21.1 % to 9.1 % . Revision rates were the same for ventriculoperitoneal ( n = 411 ) and ventriculoatrial ( n = 39 ) shunts . The predictive values of variables related to the patient , operating room , surgical technique and shunt system were analysed to determine shunt outcome . Conclusions : Right frontal placement of the ventricular catheter was associated with the lowest rate of revisions . Adjustable valves were associated with a lower risk for shunt revision . Shunt revision rates did not differ between ventriculoperitoneal and ventriculoatrial shunts Support for prospect i ve registration of protocol s for systematic review s has been gathering momentum . The PRISMA statement , a guideline for reporting systematic review s and meta-analyses of studies that evaluate health-care interventions , advocates registration . Well-conducted systematic review s are accepted as the best- quality evidence to inform policy and practice , and the dramatic upward trend in the number of systematic review s published annually ( fi gure ) is set to continue . However , there is currently no single facility for identifying this type of research in advance of the appearance of the results of the review . There is concern about and evidence of publication and selective outcome -reporting biases associated with systematic review s. An open registry of review s captured at the protocol stage would facilitate good practice in systematic review s by providing transparency of the review process and outcomes . Discrepancies between the methods of the published review and those planned in the registered protocol could be more readily identifi ed . Registration might also encourage full publication of the review ’s fi ndings and transparency in changes to methods that could bias fi ndings . In both the prevention and revelation of potential bias , registration should improve quality and increase confi dence that policy or practice informed by the fi ndings of systematic review s are indeed drawing on best- quality evidence . A registry of protocol s of systematic review s could assist those planning new review s and updating existing ones . Easy access to information about ongoing review s should help to optimise the use of fi nite re sources by enabling funding and commissioning agencies to avoid unnecessary duplication and encourage collaboration . A comprehensive registry could also create opportunities for method ological and other research , both within and across disciplines . Existing access to systematic - review protocol s is limited to the outputs of individual organisations , such as the Cochrane and Campbell Collaborations and the Joanna Briggs Institute . The National Public Health Service for Wales is piloting an All Wales Systematic Review s Register , but , up to now , there has been no central ised comprehensive registry of systematic - review protocol s. We are developing an international facility to register the details of ongoing systematic review s in health and social care . Our registry is being established with the existing platform and infrastructure that supports the Data base of Abstract s of Review s of Eff ects ( DARE ) , the NHS Economic Evaluations Data base ( NHS EED ) and the Health Technology Assessment ( HTA ) data base produced by the Centre for Review s and Dissemination . The initial scope of the registry will be limited to systematic review s of the eff ectiveness of health interventions . However , the longterm aim is for the registry to include details of all ongoing systematic review s with a health-related outcome in the broadest sense . Ultimately , inclusion will encompass systematic review s of health-care interventions , and review s of the social determinants of health , of service delivery , and of risk factors and genetic associations . Our web-based registry will off er free public access , be electronically search able , and open to all prospect i ve registrants . Registration will require the provision of a minimum data set , the completeness of which will be checked automatically before registration . After acceptance , the registry ’s entry and protocol for the review , if available , will be loaded on the data base as a permanent entry and a unique identifi cation number issued . An audit trail for any amendments to the information will be available within the record . Links to result ing publications will be added . These provisions ensure that the registry will match the relevant criteria required of clinical trials registries Background : Alzheimer disease ( AD ) has been associated with abnormal cerebral clearance of macromolecules , such as amyloid and microtubule-associated-protein tau ( MAP-τ ) . We hypothesized that improving clearance of macromolecules from the CNS might slow the progression of dementia . Objective : This prospect i ve , r and omized , double-blinded , placebo-controlled trial evaluated the safety and effectiveness of a surgically implanted shunt in subjects with probable AD . Methods : A total of 215 subjects with probable AD by National Institute of Neurological Disorders and Stroke – Alzheimer ’s Disease and Related Disorders Association criteria received either a low-flow ventriculoperitoneal shunt or a sham ( occluded ) shunt for 9 months . Longitudinal CSF sampling was performed in both active and control subjects . Primary outcome measures were the Mattis Dementia Rating Scale and the Global Deterioration Scale . CSF Aβ(1 - 42 ) and MAP-τ also were assayed . Results : After a planned interim analysis , the study was halted for futility . Using the intent-to-treat population , no between-group differences were observed in the primary outcome measures . The surgical procedure and device were associated with 12 CNS infections , some temporally associated with CSF sampling . All were treated successfully . Conclusions : We found no benefit to low-flow CSF shunting in subjects with mild to severe Alzheimer disease .  CSF infections , while treatable , occurred more frequently than expected , in some cases likely related to CSF sampling . GLOSSARY : Aβ = amyloid beta-peptides ; AD = Alzheimer disease ; ADCS-ADL = AD Cooperative Study Activities of Daily Living ; BBB = blood – brain barrier ; CP = choroid plexus ; FDA = Food and Drug Administration ; GDS = Global Deterioration Scale ; GEE = Generalized Estimating Equations ; IA = interim analysis ; ISF = interstitial fluid ; ITT = intent-to-treat ; LRP-1 = lipoprotein receptor-related protein-1 ; MAP-τ = microtubule-associated-protein tau ; MDRS = Mattis Dementia Rating Scale ; MMSE = Mini-Mental State Examination ; NAART = North American Adult Reading Test ; NINCDS-ADRDA = National Institutes of Neurological and Communicative Diseases and Stroke – Alzheimer ’s Disease and Related Disorders Association ; NPH = normal-pressure hydrocephalus ; PHF = perihippocampal fissures ; RAGE = receptor for advanced glycation end-products ; SADAS-Cog = St and ardized AD Assessment Scale – Cognitive ; SAE = serious adverse events BACKGROUND Shunt-dependent hydrocephalus is a common complication of aneurysmal subarachnoid hemorrhage ( aSAH ) . There is a need to identify patients who require ventriculoperitoneal shunt ( VPS ) insertion  so that any modifiable risk factors can be addressed early after aSAH . METHODS Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1 , a prospect i ve r and omized controlled trial of patients with aSAH treated with clazosentan .  The association between clinical and neuroimaging covariates and VPS placement was first determined by univariate analysis . Covariates with P < 0.15 on univariate analysis were then analyzed in a multivariate logistic regression model . Receiver operating characteristic curve analysis was used to define optimal predictive thresholds . The published literature was review ed to determine the overall rate of VPS insertion after aSAH . RESULTS Overall , 17.2 % ( 71/413 ) of patients required VPS insertion . Multivariate analysis demonstrated that insertion of an external ventricular drain ( odds ratio , 6.21 ; 95 % confidence interval , 2.51 - 16.91 ) and increasing volume of cerebrospinal fluid ( CSF ) drainage per day ( odds ratio , 1.004 ; 95 % confidence interval , 1.000 - 1.009 ) were associated with VPS insertion . Receiver operating characteristic curve analysis revealed an optimal daily CSF output threshold of 78 mL was predictive of VPS insertion . Among 41,789 patients with aSAH from 66 published studies , the overall VPS insertion rate was 12.7 % . CONCLUSIONS The presence of an external ventricular drain and increased daily CSF output ( above 78 mL/day ) seems to be predictive of subsequent VPS insertion after aSAH . Although we could not identify modifiable risk factors for needing a VPS , nevertheless , these findings identify patients at greatest risk of VPS placement and inform treatment decisions as well as patient expectations
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 .