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Daniel M. Sciubba, MD George I. Jallo, M.D. Johns Hopkins University

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11 diapositives · 393 Views · Nov 02, 2014

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. Shunt Infection. North American infection rate averages 5-15%

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Daniel M. Sciubba, MD George I. Jallo, M.D. Johns Hopkins University
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  1. 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

  2. Shunt Infection • North American infection rate averages 5-15% • Majority occur less than 4 months postoperatively • Associated withreduced IQ and school performance, increased risk ofseizures, and psychomotor retardation • Common cause ofshunt failure with its associated increased risk of morbidity and mortality

  3. 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

  4. 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

  5. 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%)

  6. VariableNon-ABx (n=208)ABx (n=145)p-value Age(yrs) 10.0 [2.0-16.0] 3.0 [1.0-11.0] <0.01 Sex (% female) 90 (43%) 68 (47%) 0.50 Premature* 44 (21%) 53 (37%) <0.01 Etiology of Hydrocephalus Congenital 58 (28%) 39 (27%) 0.98 Post-hemorrhagic 41 (20%) 47 (32%) <0.01 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-communicating 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%) <0.01 Set Pressure 130 (63%) 74 (51%) 0.03 Unspecified 50 (24%) 23 (16%) 0.06

  7. VariableNon-ABx (n=208)ABx (n=145)p-value Age(yrs) 10.0 [2.0-16.0] 3.0 [1.0-11.0] <0.01 Sex (% female) 90 (43%) 68 (47%) 0.50 Premature* 44 (21%) 53 (37%) <0.01 Etiology of Hydrocephalus Congenital 58 (28%) 39 (27%) 0.98 Post-hemorrhagic 41 (20%) 47 (32%) <0.01 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-communicating 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%) <0.01 Set Pressure 130 (63%) 74 (51%) 0.03 Unspecified 50 (24%) 23 (16%) 0.06

  8. 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 (p<0.01) • 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; 95%CI, 0.32-0.52, p<0.01)

  9. Infectious Agent OrganismNon-ABx (n=25)ABx (n=2) 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

  10. Incidence of shunt infection as a function of time after insertion

  11. 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