Antibiotic-impregnated%20shunt%20catheters%20decrease%20the%20incidence%20of%20shunt%20infection%20in%20the%20treatment%20of%20hydrocephalus

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Antibiotic-impregnated shunt catheters decrease
the incidence of shunt infection in the treatment
of hydrocephalus

• Daniel M. Sciubba, MD
• George I. Jallo, M.D.
• Johns Hopkins University
• Department of Neurological Surgery

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Shunt Infection

• North American infection rate averages 5-15
• Majority occur less than 4 months postoperatively
• Associated with reduced IQ and school
  performance, increased risk of seizures, and
  psychomotor retardation
• Common cause of shunt failure with its associated
  increased risk of morbidity and mortality

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Etiology of Infection

• Colonization by skin flora at the time of
  implantation
• Majority caused by gram positive cocci, with
  coagulase-negative staphylococci species
  predominating
• Antibiotic-impregnated shunt (AIS) systems have
  been shown to decrease colonization of shunt
  components by staphylococcal species
• Our study evaluate incidence of shunt infection
  after introduction of an AIS system into a
  pediatric hydrocephalus population
• Bayston R, et al. J Neurosurg 1997
• Kockro R, et al. J Med Microbiol 2000
• Hampl J, et al. Infection 2003
• Govender S, et al. J Neurosurg 2003

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Methods

• Retrospective chart review of all pediatric
  patients undergoing CSF shunt insertion over a
  3-year period between 11/01 and 3/04
• 18 months prior to October 2002, all CSF shunts
  included standard, non-impregnated shunt
  catheters
• 18 months following October 2002, all CSF shunts
  included antibiotic-impregnated shunt catheters1
• Patients were followed for 6 months, and all
  shunt-related complications, including shunt
  infection, were evaluated
• Independent association of AIS use with
  subsequent shunt infection was assessed via
  multivariate proportional hazards regression
  analysis

1Bactiseal Codman, Johnson Johnson, Boston, MA
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Patient Population

• Total 353 shunting procedures
• 55 male, 45 female
• Age 1-16 years
• Etiology of hydrocephalus
• congenital abnormality (27)
• intracranial hemorrhage (25 )
• myelodysplasia (15)
• Dandy-Walker malformation (8)
• tumor (7)
• posterior fossa cyst (6)
• meningitis (3)
• aqueductal stenosis (1)
• other etiology (9)
• Communicating (52), non-communicating (44)
• VP (92), VPl (5), VA (3)

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Variable Non-ABx (n208) ABx
(n145) p-value Age (yrs)
10.0 2.0-16.0 3.0 1.0-11.0 lt0.01 Sex
( female) 90 (43) 68 (47)
0.50 Premature 44 (21) 53
(37) lt0.01 Etiology of Hydrocephalus Congeni
tal 58 (28) 39 (27) 0.98 Post-hemorrhagic
41 (20) 47 (32) lt0.01 Myelodysplasia 32
(15) 20 (14) 0.68 Dandy-Walker 19 (9) 9
(6) 0.32 Tumor 18 (10) 5 (3) 0.05 Post.
Fossa Cyst 12 (6) 8 (6) 0.99 Meningitis 8
(4) 4 (3) 0.58 Aqueductal Stenosis 2
(1) 2 (1) 0.99 Other 17 (8) 14
(10) 0.99 Type of Hydrocephalus Non-communicati
ng 95 (46) 61 (42) 0.50 Communicating 104
(50) 78 (54) 0.48 Unclear 9 (4) 6
(4) 0.99 Initial shunt 57 (27) 49
(34) 0.20 Shunt Revision 151 (73) 96
(66) 0.20 Shunt type VP 190 (91) 136
(94) 0.91 VPl 10 (5) 7 (5) 0.99 VA 8
(4) 2 (1) 0.17 Valve Type Programmable 28
(14) 48 (33) lt0.01 Set Pressure 130
(63) 74 (51) 0.03 Unspecified 50 (24) 23
(16) 0.06
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Variable Non-ABx (n208) ABx
(n145) p-value Age (yrs)
10.0 2.0-16.0 3.0 1.0-11.0 lt0.01 Sex
( female) 90 (43) 68 (47)
0.50 Premature 44 (21) 53
(37) lt0.01 Etiology of Hydrocephalus Congeni
tal 58 (28) 39 (27) 0.98 Post-hemorrhagic
41 (20) 47 (32) lt0.01 Myelodysplasia 32
(15) 20 (14) 0.68 Dandy-Walker 19 (9) 9
(6) 0.32 Tumor 18 (10) 5 (3) 0.05 Post.
Fossa Cyst 12 (6) 8 (6) 0.99 Meningitis 8
(4) 4 (3) 0.58 Aqueductal Stenosis 2
(1) 2 (1) 0.99 Other 17 (8) 14
(10) 0.99 Type of Hydrocephalus Non-communicati
ng 95 (46) 61 (42) 0.50 Communicating 104
(50) 78 (54) 0.48 Unclear 9 (4) 6
(4) 0.99 Initial shunt 57 (27) 49
(34) 0.20 Shunt Revision 151 (73) 96
(66) 0.20 Shunt type VP 190 (91) 136
(94) 0.91 VPl 10 (5) 7 (5) 0.99 VA 8
(4) 2 (1) 0.17 Valve Type Programmable 28
(14) 48 (33) lt0.01 Set Pressure 130
(63) 74 (51) 0.03 Unspecified 50 (24) 23
(16) 0.06
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Results

• 25 (12) patients with non-impregnated catheters
  experienced shunt infection within 6-month follow
  up period
• Two (1.4) patients with antibiotic-impregnated
  catheters experienced shunt infection within the
  6-month follow-up period (plt0.01)
• Adjusting for inter-cohort differences in age,
  prematurity and post-hemorrhagic HCP via
  multivariate analysis, AIS catheters were
  independently associated with a
• 2.4-fold decreased likelihood of shunt infection
• (RR, 0.41 95CI, 0.32-0.52, plt0.01)

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Infectious Agent

• Organism Non-ABx (n25) ABx (n2)
• Staphylococcus, coagulase negative 13 1
• Staphylococcus aureus 3 1
• Streptococcus, group B 1
• Enterococcus faecium 1
• Corynebacteria spp. 2
• Gram negative rod 4
• Candida spp. 1

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Incidence of shunt infection as a function of
time after insertion
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Conclusions

• Significant reduction in CSF shunt infection was
  noted after introduction of an AIS system into a
  pediatric hydrocephalus population
• This reduction occurred over a six month
  postoperative follow up, encompassing the period
  of early infections which make up the majority of
  all shunt infections
• Future double-blinded randomized controlled
  trials must be conducted to further corroborate
  the results obtained from this retrospective study