Skip to main content
SpringerLink
Log in

Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey

  • Original Article
  • Published:
Child's Nervous System Aims and scope Submit manuscript

Abstract

Introduction

Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment.

Objective

We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures.

Methods

A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment.

Results

A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 109/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively.

Discussion

Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AIS:

Antibiotic-coated shunt

CSF:

Cerebrospinal fluid

EVD:

External ventricular drain

ISPN:

International Society for Pediatric Neurosurgery

LP:

Lumbar puncture

ST:

Shunt tap

VPS:

Ventriculoperitoneal shunt

References

  1. Kanik A, Sirin S, Kose E, Eliacik K, Anil M, Helvaci M (2015) Clinical and economic results of ventriculoperitoneal shunt infections in children. Turk Neurosurg 25:58–62. https://doi.org/10.5137/1019-5149.JTN.8540-13.2

    Article  PubMed  Google Scholar 

  2. Uche EO, Onyia E, Mezue UC, Okorie E, Ozor II, Chikani MC (2013) Determinants and outcomes of ventriculoperitoneal shunt infections in Enugu, Nigeria. Pediatr Neurosurg 49:75–80. https://doi.org/10.1159/000357384

    Article  CAS  PubMed  Google Scholar 

  3. Santos MM, Rubagumya DK, Dominic I, Brighton A, Colombe S, O’Donnell P, Zubkov MR, Härtl R (2017) Infant hydrocephalus in sub-Saharan Africa: the reality on the Tanzanian side of the lake. J Neurosurg Pediatr 20:423–431. https://doi.org/10.3171/2017.5.PEDS1755

    Article  PubMed  Google Scholar 

  4. Wright Z, Larrew TW, Eskandari R (2016) Pediatric hydrocephalus: current state of diagnosis and treatment. Pediatr Rev 37:478–490. https://doi.org/10.1542/pir.2015-0134

    Article  PubMed  Google Scholar 

  5. Raffa G, Marseglia L, Gitto E, Germano A (2015) Antibiotic-impregnated catheters reduce ventriculoperitoneal shunt infection rate in high-risk newborns and infants. Childs Nerv Syst 31:1129–1138. https://doi.org/10.1007/s00381-015-2685-7

    Article  PubMed  Google Scholar 

  6. Kanev PM, Sheehan JM (2003) Reflections on shunt infection. Pediatr Neurosurg 39:285–290. https://doi.org/10.1159/000075255

    Article  PubMed  Google Scholar 

  7. Vinchon M, Dhellemmes P (2006) Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 22:692–697. https://doi.org/10.1007/s00381-005-0037-8

    Article  PubMed  Google Scholar 

  8. Reddy GK, Bollam P, Caldito G (2012) Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg 78:155–163. https://doi.org/10.1016/j.wneu.2011.10.034

    Article  PubMed  Google Scholar 

  9. Mullan E, Lucas C, Mackie S, Carachi R (2014) Audit of ventriculoperitoneal shunt infections in paediatric patients, 2006-2013. Scott Med J 59:198–203. https://doi.org/10.1177/0036933014548665

    Article  PubMed  Google Scholar 

  10. Lang J, Amato-Watkins A, Amarasinghe S, Goetz P, Bukhari S, Leach P (2013) One year failure rate for de-novo ventriculo-peritoneal shunts in children from a small volume paediatric neurosurgical unit. Br J Neurosurg 27:503–504. https://doi.org/10.3109/02688697.2012.761674

    Article  CAS  PubMed  Google Scholar 

  11. Okoro BA, Ohaegbulam SC (1995) Experience with ventriculo peritoneal shunts at the University of Nigeria Teaching Hospital, Enugu. East Afr Med J 72:322–324

    CAS  PubMed  Google Scholar 

  12. Simon TD, Hall M, Riva-Cambrin J et al (2009) Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 4:156–165. https://doi.org/10.3171/2009.3.PEDS08215

    Article  PubMed  PubMed Central  Google Scholar 

  13. Al-Tamimi YZ, Sinha P, Chumas PD et al (2014) Ventriculoperitoneal shunt 30-day failure rate: a retrospective international cohort study. Neurosurgery 74:29–34. https://doi.org/10.1227/NEU.0000000000000196

    Article  PubMed  Google Scholar 

  14. Paudel P, Bista P, Pahari DP, Sharma GR (2020) Ventriculoperitoneal shunt complication in pediatric hydrocephalus: risk factor analysis from a single institution in Nepal. Asian J Neurosurg 15:83–87. https://doi.org/10.4103/ajns.AJNS_216_19

    Article  PubMed  PubMed Central  Google Scholar 

  15. Bir SC, Konar S, Maiti TK, Kalakoti P, Bollam P, Nanda A (2016) Outcome of ventriculoperitoneal shunt and predictors of shunt revision in infants with posthemorrhagic hydrocephalus. Childs Nerv Syst 32:1405–1414. https://doi.org/10.1007/s00381-016-3090-6

    Article  PubMed  Google Scholar 

  16. Schreffler RT, Schreffler AJ, Wittler RR (2002) Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J 21:632–636. https://doi.org/10.1097/00006454-200207000-00006

    Article  PubMed  Google Scholar 

  17. Skar GL, Beaver M, Aldrich A, Lagundzin D, Thapa I, Woods N, Ali H, Snowden J, Kielian T (2019) Identification of potential cerebrospinal fluid biomarkers to discriminate between infection and sterile inflammation in a rat model of Staphylococcus epidermidis catheter infection. Infect Immun 87. https://doi.org/10.1128/IAI.00311-19

  18. Zervos T, Walters BC (2019) Diagnosis of ventricular shunt infection in children: a systematic review. World Neurosurg 129:34–44

    Article  PubMed  Google Scholar 

  19. Dave P, Venable GT, Jones TL, Khan NR, Albert GW, Chern JJ, Wheelus JL, Governale LS, Huntoon KM, Maher CO, Bruzek AK, Mangano FT, Mehta V, Beaudoin W, Naftel RP, Basem J, Whitney A, Shimony N, Rodriguez LF, Vaughn BN, Klimo P Jr (2019) The preventable shunt revision rate: a multicenter evaluation. Neurosurgery 84:788–798. https://doi.org/10.1093/neuros/nyy263

    Article  PubMed  Google Scholar 

  20. Omrani O, O’Connor J, Hartley J, James G (2018) Effect of introduction of a standardised peri-operative protocol on CSF shunt infection rate: a single-centre cohort study of 809 procedures. Childs Nerv Syst 34:2407–2414. https://doi.org/10.1007/s00381-018-3953-0

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lee RP, Venable GT, Vaughn BN, Lillard JC, Oravec CS, Klimo P Jr (2018) The impact of a pediatric shunt surgery checklist on infection rate at a single institution. Neurosurgery 83:508–520. https://doi.org/10.1093/neuros/nyx478

    Article  PubMed  Google Scholar 

  22. Soleman J, Benvenisti H, Constantini S, Roth J (2017) Conversion of external ventricular drainage to ventriculo-peritoneal shunt: to change or not to change the proximal catheter? Childs Nerv Syst 33:1947–1952. https://doi.org/10.1007/s00381-017-3544-5

    Article  PubMed  Google Scholar 

  23. Gathura E, Poenaru D, Bransford R, Albright AL (2010) Outcomes of ventriculoperitoneal shunt insertion in sub-Saharan Africa. J Neurosurg Pediatr 6:329–335. https://doi.org/10.3171/2010.7.PEDS09543

    Article  PubMed  Google Scholar 

  24. Mwachaka PM, Obonyo NG, Mutiso BK, Ranketi S, Mwang’ombe N (2010) Ventriculoperitoneal shunt complications: a three-year retrospective study in a Kenyan national teaching and referral hospital. Pediatr Neurosurg 46:1–5. https://doi.org/10.1159/000314050

    Article  PubMed  Google Scholar 

  25. Yakut N, Soysal A, Kepenekli Kadayifci E, Dalgic N, Yılmaz Ciftdogan D, Karaaslan A, Akkoc G, Ocal Demir S, Cagan E, Celikboya E, Kanik A, Dagcinar A, Yilmaz A, Ozer F, Camlar M, Turel O, Bakir M (2018) Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study. Br J Neurosurg 32:196–200. https://doi.org/10.1080/02688697.2018.1467373

    Article  PubMed  Google Scholar 

  26. Ghritlaharey RK, Budhwani KS, Shrivastava DK, Srivastava J (2012) Ventriculoperitoneal shunt complications needing shunt revision in children: a review of 5 years of experience with 48 revisions. Afr J Paediatr Surg 9:32–39. https://doi.org/10.4103/0189-6725.93300

    Article  PubMed  Google Scholar 

  27. Lieber BA, Han J, Appelboom G, Taylor BES, Han BJ, Agarwal N, Connolly ES Jr (2016) Association of Steroid use with deep venous thrombosis and pulmonary embolism in neurosurgical patients: a national database analysis. World Neurosurg 89:126–132. https://doi.org/10.1016/j.wneu.2016.01.033

    Article  PubMed  Google Scholar 

  28. Agarwal N, Shukla RM, Agarwal D et al (2017) pediatric ventriculoperitoneal shunts and their complications: an analysis. J Indian Assoc Pediatr Surg 22:155–157. https://doi.org/10.4103/0971-9261.207624

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kandasamy J, Dwan K, Hartley JC, Jenkinson MD, Hayhurst C, Gatscher S, Thompson D, Crimmins D, Mallucci C (2011) Antibiotic-impregnated ventriculoperitoneal shunts--a multi-centre British paediatric neurosurgery group (BPNG) study using historical controls. Childs Nerv Syst 27:575–581. https://doi.org/10.1007/s00381-010-1290-z

    Article  PubMed  Google Scholar 

  30. Sood S, Canady AI, Ham SD (2000) Evaluation of shunt malfunction using shunt site reservoir. Pediatr Neurosurg 32:180–186. https://doi.org/10.1159/000028931

    Article  CAS  PubMed  Google Scholar 

  31. Stamos JK, Kaufman BA, Yogev R (1993) Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:858–862. https://doi.org/10.1227/00006123-199311000-00011

    Article  CAS  PubMed  Google Scholar 

  32. Turgut M, Alabaz D, Erbey F, Kocabas E, Erman T, Alhan E, Aksaray N (2005) Cerebrospinal fluid shunt infections in children. Pediatr Neurosurg 41:131–136. https://doi.org/10.1159/000085869

    Article  CAS  PubMed  Google Scholar 

  33. Lee JK, Seok JY, Lee JH, Choi EH, Phi JH, Kim SK, Wang KC, Lee HJ (2012) Incidence and risk factors of ventriculoperitoneal shunt infections in children: a study of 333 consecutive shunts in 6 years. J Korean Med Sci 27:1563–1568. https://doi.org/10.3346/jkms.2012.27.12.1563

    Article  PubMed  PubMed Central  Google Scholar 

  34. Habibi Z, Ertiaei A, Nikdad MS, Mirmohseni AS, Afarideh M, Heidari V, Saberi H, Rezaei AS, Nejat F (2016) Predicting ventriculoperitoneal shunt infection in children with hydrocephalus using artificial neural network. Childs Nerv Syst 32:2143–2151. https://doi.org/10.1007/s00381-016-3248-2

    Article  PubMed  Google Scholar 

  35. Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, van de Beek D, Bleck TP, Garton HJL, Zunt JR (2017) 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated Ventriculitis and meningitis. Clin Infect Dis 64:e34–e65. https://doi.org/10.1093/cid/ciw861

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Kestle JRW, Riva-Cambrin J, Wellons JC et al (2011) A standardized protocol to reduce cerebrospinal fluid shunt infection: the hydrocephalus clinical research network quality improvement initiative. J Neurosurg Pediatr 8:22–29. https://doi.org/10.3171/2011.4.PEDS10551

    Article  PubMed  PubMed Central  Google Scholar 

  37. Spiegelman L, Asija R, Da Silva SL et al (2014) What is the risk of infecting a cerebrospinal fluid-diverting shunt with percutaneous tapping? J Neurosurg Pediatr 14:336–339. https://doi.org/10.3171/2014.7.PEDS13612

    Article  PubMed  Google Scholar 

  38. Ozdol C, Gediz T, Basak AT, Basak N, Aghayev K (2019) Shunt tapping versus lumbar puncture for evaluating cerebrospinal fluid infections in a pediatric population. Turk Neurosurg 29:275–278. https://doi.org/10.5137/1019-5149.JTN.24714-18.1

    Article  PubMed  Google Scholar 

  39. Miller JP, Fulop SC, Dashti SR, Robinson S, Cohen AR (2008) Rethinking the indications for the ventriculoperitoneal shunt tap. J Neurosurg Pediatr 1:435–438. https://doi.org/10.3171/PED/2008/1/6/435

    Article  PubMed  Google Scholar 

  40. Lenfestey RW, Smith PB, Moody MA, Clark RH, Cotten CM, Seed PC, Benjamin DK Jr (2007) Predictive value of cerebrospinal fluid parameters in neonates with intraventricular drainage devices. J Neurosurg 107:209–212. https://doi.org/10.3171/PED-07/09/209

    Article  PubMed  Google Scholar 

  41. Lan C-C, Wong T-T, Chen S-J et al (2003) Early diagnosis of ventriculoperitoneal shunt infections and malfunctions in children with hydrocephalus. J Microbiol Immunol Infect 36:47–50

    PubMed  Google Scholar 

  42. McClinton D, Carraccio C, Englander R (2001) Predictors of ventriculoperitoneal shunt pathology. Pediatr Infect Dis J 20:593–597. https://doi.org/10.1097/00006454-200106000-00009

    Article  CAS  PubMed  Google Scholar 

  43. Celik U, Celik T, Tolunay O, Donmezer C, Gezercan Y, Mert K, Okten AI (2017) Platelet indices in the diagnosis of ventriculoperitoneal shunt infection in children. Turk Neurosurg 27:590–593. https://doi.org/10.5137/1019-5149.JTN.16659-15.1

    Article  PubMed  Google Scholar 

  44. Asi-Bautista MC, Heidemann SM, Meert KL, Canady AI, Sarnaik AP (1997) Tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6 concentrations in cerebrospinal fluid predict ventriculoperitoneal shunt infection. Crit Care Med 25:1713–1716. https://doi.org/10.1097/00003246-199710000-00022

    Article  CAS  PubMed  Google Scholar 

  45. Cotton MF, Hartzenberg B, Donald PR, Burger PJ (1991) Ventriculoperitoneal shunt infections in children. A 6-year study. S Afr Med J 79:139–142

    CAS  PubMed  Google Scholar 

  46. Hellbusch LC, Penn RG (1989) Cerebrospinal fluid shunt infections by unencapsulated Haemophilus influenzae. Childs Nerv Syst 5:315–317. https://doi.org/10.1007/bf00274521

    Article  CAS  PubMed  Google Scholar 

  47. Shurtleff DB, Loeser JD, Avellino AM, Duguay S, Englund JA, Marcuse EK, Peterson D (2009) Haemophilus influenzae and streptococcus pneumoniae infections in children with cerebrospinal fluid shunts. Pediatr Neurosurg 45:276–280. https://doi.org/10.1159/000228986

    Article  CAS  PubMed  Google Scholar 

  48. Heidari V, Habibi Z, Hojjati Marvasti A, Ebrahim Soltani Z, Naderian N, Tanzifi P, Nejat F (2017) Different behavior and response of staphylococcus epidermidis and streptococcus Pneumoniae to a ventriculoperitoneal shunt: an in vitro study. Pediatr Neurosurg 52:257–260. https://doi.org/10.1159/000477817

    Article  PubMed  Google Scholar 

  49. Arthur AS, Whitehead WE, Kestle JRW (2002) Duration of antibiotic therapy for the treatment of shunt infection: a surgeon and patient survey. Pediatr Neurosurg 36:256–259. https://doi.org/10.1159/000058429

    Article  PubMed  Google Scholar 

  50. Gutierrez-Murgas Y, Snowden JN (2014) Ventricular shunt infections: immunopathogenesis and clinical management. J Neuroimmunol 276:1–8. https://doi.org/10.1016/j.jneuroim.2014.08.006

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Sorar M, Er U, Ozisik P et al (2014) The impact of antibiotic-impregnated catheters on ventriculoperitoneal shunt infection. Turkish J Med Sci 44:393–396. https://doi.org/10.3906/sag-1306-15

    Article  Google Scholar 

  52. Mallucci CL, Jenkinson MD, Conroy EJ et al (2019) Antibiotic or silver versus standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation. Lancet 394:1530–1539. https://doi.org/10.1016/S0140-6736(19)31603-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Attenello FJ, Garces-Ambrossi GL, Zaidi HA, Sciubba DM, Jallo GI (2010) Hospital costs associated with shunt infections in patients receiving antibiotic-impregnated shunt catheters versus standard shunt catheters. Neurosurgery 66:284–289. https://doi.org/10.1227/01.NEU.0000363405.12584.4D

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA

    Mandana Behbahani

  2. Rush University Medical Center, Chicago, IL, USA

    Syed I. Khalid

  3. Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children´s Hospital, Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Sandi K. Lam

  4. Department of Neurosurgery, National Children’s Hospital of Costa Rica, “Dr. Carlos Saenz Herrera”, San José, Costa Rica

    Adrian Caceres

Authors
  1. Mandana Behbahani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Syed I. Khalid
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sandi K. Lam
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Adrian Caceres
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design: Dr. Adrián Cáceres.

Acquisition of data: Dr. Adrián Cáceres.

Analysis and interpretation of data: Dr. Adrián Cáceres, Dr. Sandi K. Lam, Dr. Syed Khalid, Dr. Mandana Behbahani.

Drafting of the article: Dr. Adrián Cáceres, Dr. Sandi K. Lam, Dr. Syed Khalid, Dr. Mandana Behbahani.

Critically revising the article: Dr. Adrián Cáceres, Dr. Sandi K. Lam.

Reviewed submitted version of the article: Dr. Adrián Cáceres, Dr. Sandi K. Lam.

Approved the final version of the manuscript on behalf of all authors: Dr. Adrián Cáceres.

Statistical analysis: Dr. Syed Khalid, Dr. Mandana Behbahani.

Study supervision: Dr. Adrián Cáceres.

Corresponding author

Correspondence to Adrian Caceres.

Ethics declarations

The study was approved by the National Children’s Hospital of Costa Rica Institutional Review Board with a waiver of patient informed consent, as the nature of this analysis posed minimal risk to participating individuals, and the data was presented in aggregate to minimize any risks. Completion of the survey implied consent to participate.

Conflict of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(DOCX 31 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Behbahani, M., Khalid, S.I., Lam, S.K. et al. Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey. Childs Nerv Syst 36, 2949–2960 (2020). https://doi.org/10.1007/s00381-020-04699-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00381-020-04699-z

Keywords

Search

Navigation