Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains.

PURPOSE: The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatric population. METHODS: In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series. RESULTS: One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 0-15.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17 %) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infection rate was 3.8 % (5/133). The mean duration of insertion was 10 days (range 0-42 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone. There was a significant difference (p < 0.05) when comparing our infection rate to 14 publications of infection rates in short-tunnelled EVDs; however, there was no difference when comparing our data to three publications using LTEVDs. CONCLUSION: The use of an antibiotic-impregnated LTEVD, managed according to a predefined guideline, is associated with significantly reduced infection and displacement rates when compared with contemporary series. It is suggested that this reduction is of both clinical and economic benefits.

Strategies to decrease the risk of ventricular catheter infections: a review of the evidence.

The use of antibiotic-coated external ventricular catheters has been controversial among practitioners; although several papers have documented decreased adherence of microbes to catheters treated with antibiotics, there is no universally accepted practice standard for the use of coated catheters for the prevention of clinical infection. In this paper, we review the in vivo and in vitro evidence for antibiotic-coated catheters.

Hardware-related infections after deep brain stimulation surgery: review of incidence, severity and management in 212 single-center procedures in the first year after implantation.

BACKGROUND: Device-related infection is a common occurrence after deep brain stimulation (DBS) surgery, and may result in additional interventions and a loss of efficacy of therapy. This retrospective review aimed to evaluate the incidence, severity and management of device-related infections in 212 DBS procedures performed in our institute. METHODS: Data on 106 patients, in whom 212 DBS procedures were performed between 2001 and 2011 at our institute by a single neurosurgeon (M.P.), were reviewed to assess the incidence, severity, management and clinical characteristics of infections in the first year after the implantation of a DBS system. RESULTS: Infections occurred in 8.5% of patients and 4.2% of procedures. Of the nine infections, eight involved the neurostimulator and extensions, and one the whole system. The infections occurred 30.7 days after implantation: 7 within 30 days and 2 within 6 months. Infected and uninfected patients were comparable in terms of age, sex, indication for DBS implantation and neurostimulator location. In eight cases, the system components involved were removed and re-implanted after 3 months, while in one case the complete hardware was removed and not re-implanted. CONCLUSION: The overall incidence of postoperative infections after DBS system implantation was 4.2%; this rate decreased over time. All infections required further surgery. Correct and timely management of partial infections may result in successful salvage of part of the system.

Antibiotics-impregnated ventricular catheter versus systemic antibiotics for prevention of nosocomial CSF and non-CSF infections: a prospective randomised clinical trial.

BACKGROUND: In recent years, cranial ventricular catheters impregnated with antimicrobial agents have become available. Theoretically, they provide antibiotic prophylaxis locally without the associated complications of opportunistic nosocomial infections. This study aims to compare antibiotic impregnated catheters with conventional catheters coupled with systemic antibiotics. METHODS: Patients undergoing emergency neurosurgical operations were recruited. Patients were randomly assigned to antibiotic impregnated catheters (Bactiseal, Codman, Johnson & Johnson, Raynham, MA, USA) or conventional catheters coupled with systemic antibiotics. RESULTS: 184 neurosurgical patients were enrolled between April 2004 and December 2008. Mean duration of ventricular catheter was 10 days for both groups. The proportion of patients with nosocomial infection was not significantly different: 57% (51/90) in the Bactiseal group and 51% (48/94) in the conventional group (OR 1.3, 0.7 to 2.2). There were also no differences in secondary outcome measures (CSF infection, intensive care unit stay, acute hospital stay and functional outcome) between the two groups. CONCLUSIONS: Antibiotic impregnated catheters are as effective as systemic antibiotics in the prevention of CSF infection and their corresponding nosocomial infection rates are not significantly different. The study is registered at http://www.ClinicalTrials.gov (NCT00286104).

A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics.

PURPOSE: We aim to correlate the frequency of infections after ventriculoperitoneal (VP) shunt placement in neonates with myelomeningocele (MMC) who did not receive prophylactic antibiotics to the timing of VP shunt placement and the frequency of cerebrospinal fluid (CSF) leakage at the MMC wound. METHODS: Fifty-nine newborns with MMC underwent VP shunt insertion in the period 1983-2007. We reviewed retrospectively all records. RESULTS: After MMC closure, 24 out of 59 newborns had an infection. The relative risk (RR; 95%) of having an infection is significantly higher [RR = 4,69 (1.145397-19.23568; P = .03761817)], and neuroinfection showed a tendency towards RR = 3.5 (.7067445-17.03112; P = .15414095) in newborns without symptomatic hydrocephalus at birth when we had a wait-and-watch policy (late shunt placement) compared with newborns with prompt shunt placement. The RR (95%) of having an infection [RR = 6,8 (3.314154-13.95228; P = 1.235e-07)] and also neuroinfections [RR = 4,76 (2.043019-11.09025; P = .00044478)] was highly significant if the child presented with MMC wound with CSF leakage before VP shunt insertion (Table 3). CONCLUSIONS: Centers with a conservative antibiotic policy should be even more careful to avoid CSF leakage before shunt placement as this gives a highly significant increased risk of both infections in total and neuroinfections, and they should reconsider this conservative policy in newborns with MMC due to the significantly high infection rate.

International and specialty trends in the use of prophylactic antibiotics to prevent infectious complications after insertion of external ventricular drainage devices.

BACKGROUND: External ventricular drains (EVD) are used as a method of diverting cerebral spinal fluid out of the cranium. After placement of these drains, it has been customary to initiate antibiotics to prevent drain-related infections. Prophylactic regimes include peri-operative and prolonged administration of antibiotics. Little evidence exists to support either regime. To determine current practices or to determine if an unintended consensus has developed, a survey was taken concerning antibiotic prophylaxis with EVD insertion. METHODS: E-mail survey from a membership database of the Neurocritical Care Society, a database of neurosurgeons maintained by the LSU Department of Neurosurgery and infectious diseases practitioners from a Department of Medicine database. RESULTS: There was an approximate 781 responses. Of the responders, 77% (599) were neurosurgeons, 10.5% (82) neurocritical care, 5.0% (41) intensivists, 6.5% (50) infectious diseases specialist, and 1% (9) others. The majority of responders (64%) have been in practice > 10 years. Most respondents from outside Europe recommended use of prophylactic antibiotics. Of those that did use antibiotics prophylaxis, the majority (56%) recommend use for the duration the catheter is in place. The exception is European responders used peri-operative prophylaxis most frequently. The majority of responders (78%) support a prospective trial to address this issue. CONCLUSION: The use of antibiotics prophylaxis after EVD placement is disparate among specialties that deal with EVD placement and complications. There is no consistent practice pattern based on specialty, locale, and years of practice. The majority of all responders felt a prospective trial was warranted.

Risk factors for infections related to external ventricular drainage.

BACKGROUND: External ventricular drainage (EVD) is frequently used in neurosurgery for cerebrospinal fluid (CSF) drainage in patients with raised intracranial pressure. The major complication of this procedure is an EVD-related infection, i.e., meningitis or ventriculitis. The purpose of the present retrospective single centre study is to assess the possible causes of these infections. PATIENTS AND METHODS: Two hundred and twenty-eight patients were included in the period from January 1993 until April 2005. Patient and disease demographics, as well as EVD data, and the occurrence of infection were reviewed, compared, and included in a risk-analysis study. RESULTS: The population's mean age was 56 +/- 15 years and the sexes were equally distributed. Most frequently, the indication for EVD was hydrocephalus due to intraventricular haemorrhage (48.2%). An infection was documented in 23.2% of all patients. Duration of EVD drainage appeared to be a risk factor for infection (>11 days: OR 4.1; 95% CI 1.8-9.2, p = 0.001). CSF sampling frequency was also a significant risk-factor (no sampling: OR 0.2, 95% CI 0.2-0.5, p = 0.003). CONCLUSIONS: We found a relatively high percentage of EVD-related infections. After multivariate analysis there appears to be a relation with duration of drainage and frequent CSF sampling. As a result, a new EVD protocol is proposed in our institution that we believe will decrease the number of EVD-related infections to a minimum.

Management of Traumatic Brain Injury.

Traumatic brain injury remains a serious public health problem, causing death and disability for millions. In order to maximize outcomes in the face of a complex injury to a complex organ, a variety of advanced neuromonitoring techniques may be used to guide surgical and medical decision-making. Because of the heterogeneity of injury types and the plethora of treatment confounders present in this patient population, the scientific study of specific interventions is challenging. This challenge highlights the need for a firm understanding of the anatomy and pathophysiology of brain injuries when making clinical decisions in the intensive care unit.

External ventricular drain infection: the effect of a strict protocol on infection rates and a review of the literature.

External ventricular drains (EVDs), like any surgically-implanted foreign body, are at risk of infection. We present the results of a completed audit loop following introduction of an evidence-based protocol for their insertion and management. There were two phases over a 2-year period. Phase 1 was a retrospective audit of our EVD infection rate. Phase 2 was a prospective audit of the infection rate subsequent to the introduction of a protocol for the insertion and management of EVDs. In phase 1, the infection rate was 27%. In phase 2, the infection rate was 12%. This was a statistically significant reduction (p < 0.05, Chi-squared test). EVD infection is unfortunately a common clinical problem and associated with potential morbidity and mortality. This study demonstrates that adherence to an evidence-based protocol for their insertion and management is associated with a significant reduction in the infection rate.

Immune reactions to Listeria monocytogenes in the brain.

Listeria monocytogenes (LM) is a common pathogen of cerebral infections. Experimental studies in mice have revealed that epithelial cells of the choroid plexus, ependymal cells, macrophages/microglia, and neurons are the target cells of LM. For the intracerebral pathogenesis of LM cell-to-cell spread via phospholipase C was particularly important. However, phospholipase C-deficient LM were not completely attenuated and, therefore, other virulence factors may also contribute to the intracerebral spread of LM. In general, all mice suffering from cerebral listeriosis rapidly succumbed to the disease. Active systemic immunization prior to intracerebral infection reduced the mortality rate to 40%. The favorable prognosis of immunized mice correlated with a reduced intracerebral bacterial load, an increased recruitment of protective CD4+ and CD8+ T cells as well as an upregulated mRNA production of protective cytokines.

Infection rates in standard vs. hydrogel coated ventricular catheters.

BACKGROUND: Infection related to external ventricular drain (EVD) use is a common neurosurgical complication. Modified catheters with a hydrophilic surface may impede bacterial adherence and thereby reduce catheter related cerebrospinal fluid (CSF) infection. METHODS: A prospective randomized clinical trial compared the occurrence of CSF infection related to use of either standard silastic or hydrogel coated EVD catheters (Bioglide, Medtronic). Enrolment was available to all adult neurosurgery patients undergoing placement of a first EVD, at three university centers. The catheters were presoaked in a low concentration of bacitracin solution for 5-10 minutes prior to insertion. Bacterial infection was defined by heavy growth in a single CSF sample or light/medium growth in two consecutive samples. A secondary analysis was also conducted for "probable" CSF infection, including patients started on antibiotics after light/medium growth in a single CSF sample. Statistical analyses included Kaplan-Meier survival curve estimates accompanied by Log Rank and Breslow tests. RESULTS: There were 158 randomized patients available to assess for EVD related infection of CSF. The two study groups had similar clinical characteristics including average duration of EVD use (8 +/- 4 days). Definite CSF infection occurred in seven and probable infection in another six (8% total). Infection incidence rose steadily from day 2 (1%) to day 11 (11%). There was no difference of daily occurrence of EVD infection between the two catheter types. CONCLUSIONS: Infection remains a common hazard in the use of EVD, and we found no reduction of infection using the hydrogel-coated catheters when presoaked in low concentration bacitracin solution.

Infections and re-infections in long-term external ventricular drainage. A variation upon a theme.

BACKGROUND: The infection of the external ventricular drainage (EDV) remains the main morbidity and mortality associated with this procedure, in the setting of the treatment of hydrocephalus and its complications, leading to excess of hospitalization with annual economic burden. METHODS. In this 3-year retrospective study we selected and reviewed the records of 15 of 143 patients (mean age 34 years with range from 1 months to 70 years; 12 males and 3 females) undergone to prolonged EVD in the setting of management of hydrocephalus (5 patients because of acute ventricular dilation post-intraventricular hemorrhage or post-hemorrhagic HCP, 8 because of V-P shunt infection, 1 because of post-traumatic HCP and 1 because of shunt malfunction by elevated CSF protein) and developing a shunt infection or one or more superinfection. RESULTS: There was a 26% mortality and a 13% morbidity (1 patient had GOS score of 2, 1 score of 3 and 3 score of 5). The pathogens yielded by CSF culture were normal or transient flora of the patient's skin. The causes of infection were carefully analyzed. CONCLUSIONS: Based on our experience the management of infection in long-term EVD includes: the standardization of the environment of the surgery achieved with a) use of prophylactic antibiotics; b) preparation of the patient and sterile field; c) no touch technique. After implantation of EVD the risk of infection must be minimized by carefully nursing care of EVD, and administration of above prophylactic antibiotics. CSF must be collected for culture and cell count, glucose and protein when clinically indicated. When infection o reinfection is demonstrated by CSF culture then it is advisable to remove the entire hardware and start the antibiotic therapy intravenously and intraventricularly basing on susceptibility tests, CSF penetration of antibiotics, their bactericidal action, toxicity, specificity and cost. Regard to the duration of the therapy, a practical guide is treating for 10-14 days after three consecutive CSF sterile cultures. Thus, convention of EVD to a shunt can be performed within 3 weeks from admission, in the best favourable cases, decreasing the duration of hospital stay and the overall cost of neurosurgical management of the cerebral pathology requiring as therapeutic adjunct and EVD.

Antibiotic impregnated catheter coverage of deep brain stimulation leads facilitates lead preservation after hardware infection.

Deep brain stimulation (DBS) has become a reliable and effective treatment for many disorders. However, the risk of long-term hardware-related complications is notable, and most concerning is hardware-related infections. Given the risk of hardware removal in the setting of infection, we retrospectively examined the implementation of a novel technique using antibiotic covered catheter protection of DBS leads after infection. The effect on hardware salvage and ease of reimplantation of the DBS extension and implantable pulse generator (IPG) was examined. A total of nine (9%) out of 100 DBS patients met the inclusion criteria with 11 DBS hardware-related infections at either the frontal, parietal, or IPG sites, from June 2003 to November 2010, at our institution. Subsequent to the initial patient in the series, a total of eight patients had placement of a short segment (approx. 4 cm long) of antibiotic impregnated catheter (Bactiseal, Codman, Johnson & Johnson, Raynham, MA, USA) over the distal end of the DBS leads at the parietal incision. Seven of these eight patients presented with pus and deep tissue infections around the hardware at either the frontal, parietal, or chest incisions. In seven of these eight patients (87.5%) we were able to protect and salvage their DBS leads without need for removal. In conclusion, this novel technique provides a simple reimplantation operation, with a decreased risk of DBS lead damage. It may improve the preservation of DBS leads when hardware infection occurs, is inexpensive, and confers no additional risks to patients.

A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections.

OBJECT: An important complication of external CSF drainage is bacterial meningitis or ventriculitis, resulting in increased morbidity, mortality, and health care costs. In 2003, a high rate (37%) of probable drain-related infections was identified at the authors' hospital. A multidisciplinary working group was installed to reduce this incidence to < 10% within 1.5 years. METHODS: An intervention strategy based on 5 pillars (increased awareness, focused standard operating procedures, a diagnostic and therapeutic algorithm, timely administration of prophylaxis, and improvement of the drainage system) was designed and implemented from 2004 to 2006. During this period all patients with external CSF drainage were prospectively monitored. RESULTS: Between 2004 and 2006, there were 467 patients in whom 579 drains (external ventricular and external lumbar) had been placed. The overall incidence of drain-related infections was 16.2% in 2004, 8.9% in 2005, and 11.3% in 2006. For external lumbar drains the number of infections per 100 drain days was 2.4 in 2004, 0.6 in 2005, and 0.8 in 2006. For external ventricular drains these rates were 1.7, 1.0, and 1.2, respectively. Meanwhile, the causative noncutaneous microorganisms, indicative for systemic-contamination during manipulation, decreased. By retrospective analysis, the proportion of patients with a probable drain-related infection decreased from 37% in 2003 to 9% in 2005 and 2006. CONCLUSIONS: The authors' multidisciplinary approach in which different preventive measures were combined was associated with a significant reduction in the incidence of drain-related secondary meningitis, and thus provides an important improvement of patient safety.

Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review.

OBJECT: Systemic antibiotics and antibiotic-impregnated shunt (AIS) systems are often used to prevent shunt infection. The authors conducted a systematic review to evaluate its effectiveness of antibiotics in patients who underwent placement of intracranial ventricular shunts. METHODS: The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, and the meeting proceedings from the American Association of Neurological Surgeons and from the European Association of Neurosurgical Societies until June 2005. Randomized and quasi-randomized trials comparing the use of prophylactic antibiotics (either systemic or AIS systems) in intracranial ventricular shunt procedures with placebo or no antibiotics were included in the review. RESULTS: Seventeen trials involving 2134 patients were included. Results from the meta-analysis showed that the use of systemic antibiotic prophylaxis for internal shunts was associated with a decrease in shunt infection (odds ratio 0.51; 95% confidence interval 0.36-0.73). The authors found no significant differences between the subgroups evaluated in type of internal shunt (ventriculoperitoneal/ventriculoatrial), age, or duration of the administration of antibiotics. CONCLUSIONS: The authors found a benefit of systemic prophylactic antibiotics in preventing shunt infection, regardless of the patient's age and the type of internal shunt used. The benefit of its use after the first 24 hours postoperatively remains uncertain. Future trials should be conducted to evaluate the effectiveness of different regimens of systemic antibiotics rather than placebo, namely single preoperative dose versus multiple doses. It should also be mandatory to evaluate the effectiveness of systemic prophylactic antibiotics for external ventricular drains. Evidence suggests that antibiotic-impregnated catheters reduce the incidence of shunt infection, although more well-designed clinical trials are needed.

Extended subcutaneous tunnelling technique for external ventricular drainage.

Infection is a serious complication of external ventricular drain (EVD) and various strategies have been adopted to minimize its occurrence. The use of an extended subcutaneous tunnel (50-60 cm) was previously described, but has since received little attention in the literature. The authors reviewed their experience with this technique, with emphasis on the rate of infection and predisposing risk factors. This is a retrospective review of 114 patients who received EVD with extended subcutaneous tunnel ('long EVD'). Fourteen of the 114 patients underwent more than one insertion, and a total of 133 cases of 'long EVD' were included. The mean duration of drainage was 20 days. One-hundred-and-three cases started without pre-existent infection and seven became infected, yielding an overall infection rate of 6.8%. The majority of infections were found within the first 5 days and in the third week of drainage. There was, however, no statistically significant difference in daily infection risks between the first, second and third weeks. Only intraventricular instillation of urokinase was identified as a statistically significant risk factor. Non-infective complications occurred in 17 cases (12.8%). In the present study, the overall infection rate of the 'long EVD' was comparable with that of conventional EVD, as reported by other authorities in the literature. The extended subcutaneous tunnel technique did not affect the daily infection risk on a week-to-week basis. The 'long EVD' does not appear to offer any distinct advantage over the standard tunnelling technique in our unit. However, this is essentially an audit within a single centre, and the findings should be interpreted with caution and with the understanding that individual institutions may have their unique patterns and risks of EVD infection.