title: Antimicrobial suture wound closure for cerebrospinal fluid shunt surgery: a prospective, double-blinded, randomized controlled trial. A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Efficacy of intraoperative irrigation with saline for preventing shunt infection. A randomized trial of ceftriaxone versus trimethoprim-sulfamethoxazole to prevent ventriculoperitoneal shunt infection. Vancomycin versus cefazolin prophylaxis for cerebrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. A standardized protocol to reduce cerebrospinal fluid shunt infection: the Hydrocephalus Clinical Research Network Quality Improvement Initiative. A randomised control trial on the use of topical methicillin in reducing post-operative ventriculoperitoneal shunt infection. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article.
abstract: 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 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 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 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 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 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 A double-blind r and omised control study was conducted on all patients who were admitted or referred to the Department of Neurosurgery , Sultanah Aminah Hospital , Johor Bahru , with a diagnosis of hydrocephalus where a ventriculoperitoneal shunt was indicated . METHODS The period of study was from November 2005 to May 2007 , and the follow-up period was 3 months after surgery . R and omisation was carried out in the operating room prior to the procedure . The scrub nurse selected a sealed envelope , which contained the assignment of each patient to 1 of 2 treatment groups : Group 1 patients were treated with topical methicillin , and Group 2 patients were not treated with topical methicillin . Prophylactic antibiotic , cefuroxime ( 25 mg/kg ) was given intravenously at induction . St and ard sterile operative technique was followed in preparing and draping the patients . RESULTS A total of 90 patients were recruited in the study , and 13 ( 14.4 % ) patients developed an infection within 3 months post-operation . Group 1 had a 8.9 % risk of infection , and Group 2 had a 20 % risk ; however , there was no statistically significant post-operative ventriculoperitoneal shunt ( VPS ) infection reduction with the use of topical methicillin in VPS surgery ( P = 0.230 ) . Multivariate analysis showed that only duration of surgery had a significant influence on the incidence of post-operative VPS infection in the non-methicillin group ( P = 0.02 ) . The non-methicillin group had an 8 times greater risk of developing post-operative VPS infection than the methicillin group if surgery lasted longer than 1 hour . CONCLUSION Topical methicillin had no significance in the reduction of post-operative VPS 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 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 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
target: 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
background: 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 .