Shunt infection prevention practices in Hydrocephalus Clinical Research Network–Quality: a new quality improvement network for hydrocephalus management
Authors: Tamber Mandeep S. , Jensen Hailey , Clawson Jason , Nunn Nichol , Wellons John C. , Smith Jodi , Martin Jonathan E. , Kestle John R. W. , _ _ , Meltzer Hal , Hamilton Kimberly , Dekeseredy Patricia , Warf Benjamin , Northam Weston , Weber Daniel , Porter Adam , Papadakis Joanna , Mosher Amanda , Piatt Joseph , Heuer Gregory , Lopez Lina , Maugans Todd , Clerkin Patricia , Mehta Vivek , Souster Jenny , Elliott Cameron , Beaudoin Wendy , Burton Heather , Bhattacharya Sudeshna , Gnenz Sydney , Halvorson Kyle , Ingram Katherine , Nguyen Victoria , Smith Jodi , Delaney Erin , Cero Heather , Vance Emily , Bristol Ruth , Gaiser Jeremy , Niazi Toba , Bollerman Kari , Benitez Jonathan , Gonda David , Ravindra Vijay , Alvarez Aida , Gupta Nalin , Mahuvakar Shivani , Pen Catalina , Foy Andrew , Kim Irene , Nader Amy , Gonzales Allison , Raskin Jeffrey , Bowman Robin , Dziugan Klaudia , Botros James , Spader Heather , Lujan Aaron , Brown Jaquelyn , Ahmed Raheel , Bock Jenna , Wilbrand Stephanie , Oimoen Maggie , Endres McKenzie , Reynolds Renee , Gernsback Joanna , Omini Michael , Muhonen Michael , Romero Bianca , Ritter Ann , Sandoval-Garcia Carolina , Venteicher Emma , Kann Leah , Kobets Andrew , Ahmad Samuel , Castillo Ashley , Walling Simon , McNeely Daniel , Szego Sarah , Martin Jonathan , Hersh David , Stoltz Petronella , Mahaney Kelly , Bet Anthony , Valladrez Adrian , Morton Gabriella , Partington Michael , Kyle Dante , Whittemore Brett , Tailor Jignesh , Lowe Marissa , Shirrell Mariah , Vestal Matty , Perry Beth , Benitez-Rosas Hazani , Salgado Amayrani Salvario , Souweidane Mark , Villamater Francis , Morgenstern Peter , Melo Leslie , Wait Scott , Shears Danielle , Elbabaa Samer , Olavarria Greg , Parrimon Yazandra , Williamson Alice , Madura Casey , Wiersema Sarah , Westenbroek Sarah 
Published: November 2023

OBJECTIVE
Knowledge-based tools used to standardize perioperative care, such as the shunt infection prevention protocol of the Hydrocephalus Clinical Research Network (HCRN), have demonstrated their ability to reduce surgeon-based and center-based variations in outcomes and improve patient care. The mere presence of high-quality evidence, however, does not necessarily translate into improved patient outcomes owing to the implementation gap. To advance understanding of how knowledge-based tools are being utilized in the routine clinical care of children with hydrocephalus, the HCRN-Quality (HCRNq) network was started in 2019. With a focus on CSF shunt infection, the authors present baseline data regarding CSF shunt infection rates and current shunt infection prevention practices in use at HCRNq sites.

METHODS
Baseline shunt surgery practices, infection rate, and risk factor data were prospectively collected within HCRNq. No standard infection protocol was recommended, but site use of a protocol was implied if at least 3 of 6 common shunt infection prevention practices were used in > 80% of shunt surgical procedures. Univariable and multivariable analyses of shunt infection risk factors were performed.

RESULTS
Thirty sites accrued data on 2437 procedures between November 2019 and June 2021. The unadjusted infection rate across all sites was 3.9% (range 0%–13%) and did not differ among shunt insertion, shunt revision, or shunt insertion after infection. Protocol use was implied for only 15/30 centers and 60% of shunt operations. On univariable analysis, iodine/DuraPrep (OR 0.57, 95% CI 0.37–0.88, p = 0.02) and the use of an antibiotic-impregnated catheter in any segment of the shunt (or both) decreased infection risk (OR 0.53, 95% CI 0.34–0.82, p = 0.01). Iodine-based prep solutions (OR 0.56, 95% 0.36–0.86, p = 0.02) and the use of antibiotic-impregnated catheters (OR 0.52, 95% CI 0.34–0.81, p = 0.01) retained significance in the multivariable model, but no relationship between protocol use and infection risk was demonstrated in this baseline analysis.

CONCLUSIONS
The authors have demonstrated that children undergoing CSF shunt surgery at HCRNq sites share similar demographic characteristics with other large North American multicenter cohorts, with similar observed baseline infection rates and risk factors. Many centers have implemented standardized shunt infection prevention practices, but considerable practice variation remains. As such, there is an opportunity to decrease shunt infection rates in these centers through continued standardization of care.