Subcutaneous ventricular catheter reservoir and ventriculoperitoneal drain-related infections in preterm infants and young children

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1 ORIGINAL ARTICLE Subcutneous ventriculr ctheter reservoir nd ventriculoperitonel drin-relted infections in preterm infnts nd young children N. Bruinsm 1, E. E. Stobberingh 1, M. J. H. M. Herpers 2, J. S. H. Vles 3, B. J. Weber 3 nd D. A. W. D. Gvilnes 4 1 Deprtment of Medicl Microbiology, 2 Deprtment of Neurosurgery, 3 Deprtment of Neurology nd 4 Deprtment of Peditrics, University Hospitl Mstricht, Mstricht, The Netherlnds Objective In the period Jnury 1990 to September 1997, 70 ptients, ged under 6 yers were treted for hydrocephlus with subcutneous ventriculr ctheter reservoir nd/or ventriculoperitonel drin t the University Hospitl of Mstricht. Methods By mens of retrospective chrt nlysis, the number of shunt infections nd relted risk fctors were nlyzed. Results Twenty-one ptients (30%) developed one or more infections, with n infection rte of 15.2% per surgicl event. For n implnted reservoir or drin, the infection rtes were 15.9 nd 16.4%, respectively. The study group consisted of 39 (55.7%) preterm infnts (³37 weeks) nd 31 (44.3%) full-term infnts ( 37 weeks), with infection rtes of 33.3 nd 25.8%, respectively. At the first surgicl intervention 28 ptients (40%) hd postmenstrul ge less thn 37 weeks, with n infection rte of 46.4%. At the time of surgery, 69.7% of the ptients were ged less thn 6 months, with n infection rte of 19.6%. The most frequent custive microorgnism of the shunt infections ws Stphylococcus epidermidis (42.1%). Conclusions Premturity is n importnt risk fctor for ventriculr ctheter reservoir nd ventriculoperitonel drin-relted infections, especilly for ptients with postmenstrul ge of less thn 37 weeks t their initil shunt plcement nd extreme low birth weight infnts hve high risk for infection. In our opinion the use of dequte ntibiotic prophylxis nd optiml infection control mesures re necessry to keep the rte of infection s low s possible. Keywords hydrocephlus, preterm infnts, ventriculoperitonel drin, subcutneous ventriculr ctheter reservoir, shunt infection Accepted 29 October 1999 Clin Microbiol Infect 2000; 6: INTRODUCTION The percentge of shunt infections rnged in severl retrospective studies from 0.17 to 39% [1 3, 4 12]. In ptients with subcutneous ventriculr ctheter reservoirs (VCR) or ventriculoperitonel drins (VPD), the vritions in infection rte re probbly due to differences in the ge of the ptients, definition of infection, study methodology nd peri-opertive mesures. Shunt infections re ssocited with mny fctors, including mong others, ge nd weight of the ptient, experience of the Corresponding uthor nd reprint requests: Ellen E. Stobberingh, Deprtment of Medicl Microbiology, University Hospitl Mstricht, P. Debyeln 25, PO Box. 5800, 6202 AZ Mstricht, The Netherlnds Tel: Fx: E-mil: PTER@LMIB.AZM.NL neurosurgeon, plce of surgery (intensive cre unit or operting room), durtion of surgery, type of shunt, nd use nd durtion of prophylctic ntibiotics [1,4,7,10,13]. The improvement of surgicl techniques hs mde the plcement of shunt devices in high-risk newborns suffering from hydrocephlus possible t very erly stge. However, the incidence of complictions (dysfunction nd/or infection) remins importnt, especilly in low birth weight infnts (LBWI, birth weight less thn 2000 g). The im of the study ws to describe the number of VCRnd VPD-relted infections nd to nlyze the possible risk fctors in ptient popultion of preterm infnts nd young children. PATIENTS AND METHODS By mens of retrospective chrt nlysis, shunt infections were nlyzed, in 70 ptients less then 6 yers of ge, who required 2000 Copyright by the Europen Society of Clinicl Microbiology nd Infectious Diseses

2 Bruinsm et l Shunt infections in preterm bbies nd infnts 203 opertions due to hydrocephlus between Jnury 1990 nd September The opertions consisted of insertion, revision nd removl of VCRs s well s VPDs. Prophylctic ntibiotics were given for 24 h pre-, per- nd postsurgery, dministered intrvenously nd/or intrtheclly depending on the type of shunt. The doses dministered depended on the ge nd weight of the ptients. Informtion ws recorded on the prevlence of infection, demogrphic informtion on the ptient, clinicl symptoms, use of prophylctic ntibiotics, surgicl dt, lbortory results, the presence of shunt dysfunction nd the time period between surgery nd infection. When VCR infection ws dignosed, tretment with vncomycin, both intrvenously nd intrtheclly, in combintion with intrvenous ceftzidime ws dministered until the custive microorgnism ws identified. In the cse of Stphylococcus epidermidis, tretment with vncomycin, dministered both intrvenously nd intrtheclly, ws continued for 14 dys (fter negtive cerebrospinl fluid (CSF) cultures) nd ceftzidime ws stopped. A mg dose of vncomycin ws given intrtheclly three times dily. If the CSF cultures remined positive, the VCR ws revised. When VPD infection ws dignosed, the VPD ws removed nd temporry VCR ws instlled. For Grm-negtive microorgnism, intrvenous ceftzidime ws dministered for 21 dys (fter negtive CSF cultures) nd vncomycin ws stopped. The dosge depended on the gesttionl ge nd weight of the ptient. All dt were registered nd nlyzed using SPSS progrm, version 7.0 (SPSS inc., Chicgo, IL, USA). The chrcteristics of the study group re outlined in Tble 1. Definitions Shunt infection. A shunt infection ws bsed on positive CSF cultures nd clinicl symptoms (incresed intrcrnil pressure, wound dehiscence nd/or erythem, fever nd meningism), which led to therpeutic interventions, i.e. ntibiotic therpy nd/or shunt revision [3,5,6]. VCR-tpping relted infection. An infection 10 dys or more fter surgery, cused by repeted tpping of VCR. Surgicl infection. When VPD or VCR becme infected within 9 dys of surgery, it ws considered surgicl infection. Shunt revision. An opertion resulting in removl of VCR or VPD, or replcing VPD by VCR followed by intrthecl ntibiotic therpy, performed fter shunt infection ws dignosed. RESULTS In the period Jnury 1990 to September 1997, 70 ptients, then ged under 6 yers, were treted for hydrocephlus, by insertion of VPD or VCR. This popultion of 70 children Tble 1 Chrcteristics of the group of children studied Infected/totl (%) Number of ptients 21/70 (30) Gesttionl ge ³28 weeks 4/7 (57.1) weeks 9/32 (28.1) weeks 8/31 (25.8) Birthweight ³1000 grm (ELBWI) 4/11 (36.4) g 5/14 (35.7) g 3/7 (42.9) 2000 g 9/38 (23.7) Postmenstrul ge ³28 weeks 1/2 (50) (PMA) t the first weeks 12/26 (46.2) shunt plcement 37 weeks 8/42 (19) Number of opertions 30/198 (15.2) Age ³6 months 27/138 (19.6) 6 months 1 yers 1/22 (4.5) 1 6 yers 2/38 (5.5) Type of shunt VCR 11/69 (15.9) VPD 19/116 (16.4) unknown 0/13 underwent 198 opertions representing n verge of 2.8 opertions per ptient. Popultion Of the 70 ptients, 39 were preterm infnts (³37 weeks) nd 31 were full term ( 37 weeks), with n infection rte of 33.3% (13 of 39) nd 25.8% (8 of 31), respectively (Tble 1). Thirtytwo ptients (45.7%) were LBWI (¾2000 g), mong whom 11 were extremely low birth weight infnts (ELBWI, ³1000 g) (Tble 1). At the first surgicl intervention two ptients hd postmenstrul ge (PMA) of less thn 28 weeks, 26 ptients hd PMA between 28 nd 37 weeks nd 42 hd PMA of more thn 37 weeks, with infection rtes of 50, 46.2 nd 19%, respectively, (Tble 1). All of the infected preterm infnts hd periventriculr-intrventriculr hemorrhge (PVH-IVH). The initil plcement consisted of VCR (37 of 70) or primry VPD (33 of 70), fter which infection occurred in 12 (32.4%) nd nine (27.3%) ptients, respectively. Surgery Of the 70 ptients, 21 hd one or more infections, resulting in totl of 30 infections (15.2%) fter the 198 opertions performed. The men durtion of these opertions ws 45 min, rnging from 10 to 100 min. In this study no significnt reltion

3 204 Clinicl Microbiology nd Infection, Volume 6 Number 4, April 2000 between durtion nd the number of infections ws found. Ten of the infections were surgicl infections nd 10 were tprelted. The other 10 cses could not be clerly defined. At the time of surgicl intervention 138 ptients (69.7%) were less thn 6 months of ge, 22 (11.1%) were ged between 6 months nd 1 yer nd 38 (19.2%) were ged between 1 nd 6 yers. The infection rtes were 19.6, 4.5 nd 5.5%, respectively, (Tble 1). In totl 69 VCRs nd 116 VPDs were plced or removed, nd 11(15.9%) nd 19 (16.4%), respectively, becme infected. In 13 of the 198 opertions the type of shunt plced ws not mentioned. The density incidence of VCR infections ws 0.38 infections per 100 VCR-dys. Neurosurgeons Ten infections most probbly originted during surgery. Four neurosurgeons performed the mjority of the opertions. After 57, 57, 38 nd 24 opertions performed by ech of these surgeons, two, four, two nd two becme infected, respectively. Shunt dysfunction Dysfunction of the shunt without n intercurrent infection ws found 41 times. Of the 30 infections, 13 (43.3%) were ccompnied by shunt dysfunction. DISCUSSION Bcteriologicl results A totl of 190 positive cerebrl spinl fluid (CSF) cultures were obtined from the 21 infected ptients. The most frequently isolted microorgnism ws S. epidermidis (42.1%), followed by other cogulse-negtive stphylococci (14.7%) (Tble 2). Prophylctic ntibiotics During 12 of the 198 opertions no prophylctic ntibiotics were dministered. Four of these 12 cses were infected (33.3%). The most frequently used therpy ws combintion of rifmpicin nd flucloxcillin (n = 76), with n infection rte of 19.7%. The rte of infection fter cefzolin (n = 31) ws 12.9% nd fter vncomycin either both intrvenously nd intrtheclly or in combintion with other gents (n = 19) no infections were found. All ntibiotics used were well tolerted. Tble 2 Micro-orgnisms isolted from 190 positive CSF smples Isolted microorgnisms Species No. % Stphylococcus epidermidis Cogulse negtive-stphylococci Stphylococcus ureus Enterococcus feclis Bcillus cereus Propionibcterium sp Grm positive rods Grm positive cocci Enterobctericee b rest not further specited (i.e. norml skin flor). b Klebsiell spp., Escherichi coli, Proteus mirbilis. The mjority of the ptients were preterm infnts (55.7%), high-risk group for shunt infections. The infection rte of preterm infnts (33.3%) ws higher thn tht of the full-term bbies (25.8%). This is probbly due to the unstble, immture stte of the ptients, the low birth weight, the high number of skin bcteri [4] nd the often long hospitliztion which cuses more coloniztion with specific nosocomil microorgnisms [4,14,15]. In generl, preterm infnts with posthemorrhgic hydrocephlus were treted with temporry VCR, becuse of the high CSF-protein concentrtion nd possible blood clots which could obstruct primrily plced definitive VPD [10]. According to the study of Benzel et l. (1993), erly plcement of VCR ws ssocited with decrese in the overll shunt infection rte, which is substntil in preterm infnts [3]. Usully, fter reduction of the CSF-protein concentrtion the VCR will be replced by definitive VPD, if necessry. Tretment with n initil VCR includes the dditionl risk of infections cused by repeted tpping (twice dily). The plcement of these VCR s is usully performed in our neontl intensive cre unit, which we previously reported to be suitble for such surgery [16].In ddition to the initil plcement of VCR, these reservoirs were lso used for intrthecl ntibiotic tretment fter VPD-relted infection. Importnt chrcteristics of our study were: the substntil number of preterm infnts (55.7%) nd LBWI (36.4%), of whom 11 (15.7%, of the totl popultion) were ELBWI; the number of ptients (40%) who hd their first surgicl intervention t PMA less thn 37 weeks; the number of ptients who underwent n opertion before the ge of 6 months (69.7%); nd the implnttion of VCRs. At the time of surgery 47.8% of the ptients were less thn 2 months of ge. These chrcteristics mke it difficult to compre our dt with those of other studies, mentioned in Tble 3. Tking into ccount the men gesttionl ge of 29.4 weeks nd the use of ventriculr reservoirs, the study most similr to ours ws tht of Benzel et l. [3]. Their infection rte of 32% ws in ccordnce to our

4 Bruinsm et l Shunt infections in preterm bbies nd infnts 205 Tble 3 Survey of studies of shunt infections Authors nd yer Preterm infnts/ Infected/number Age of surgery of ll ptients Infections/number of [reference] number of ptients of ptients (%) (m = month, y = yer) opertions of ll ptients (%) Choux et l [11] 73/600 2/600 (0.33) ³6 m, 32% 6 m 1 y, 9% 2/1197 (0.17) 1 y,59% Renier et l [14] /802 /802 90/1141 (7.9) Fillce et l [7] 12/51 2/51 (3.9) ³1 y, 46% 1 12 y, 16% 2/67 (2.9) y, 7.8% 20 y, 29% Willims et l [12] 68/659 (10.3) Pople et l [4] /294 /294 ³6 m, 38.2% 6 m, 61.8% 44/466 (10) Kontny et l [2] /254 25/254 (9.8) neontes, 22.6% 1 6 y, 38.9% 28/350 (8) 7 18 y, 41.7% Ershin et l [1] /307 39/307 (12.7) ³1 y, 86.6% 1 y, 31.4% 46/612 (7.5) Borgbjerg et l [5] /884 65/884 (7.4) ³1 y, 28.7% 1 14 y, 21% / 15 y, 50.3% Benzel et l [3] /41 13/41 (32) / Bruinsm et l /70 21/70 (30) ³6 m, 68.7% 6 m 1 y, 12.6% 30/198 (15.2) 1 6 y, 18.7% men gesttionl ge of 29.4 weeks findings. The infection rtes of the other studies were clerly lower, but none of hd the sme high number of preterm infnts nd children less then 6 months of ge t the time of surgery. Choux et l. (Tble 3) [11] especilly described very low infection rte, but they neither mentioned the ge t which surgery ws performed, nor the incidence of posthemorrhgic hydrocephlus in the group of 73 preterm infnts. Initil plcement, erly in the postntl period, hs significntly higher infection risk thn lter plcement [10]. This is confirmed by our dt. Of the 28 ptients who hd PMA less then 37 weeks t their initil plcement 46.4% were infected. Severl preopertive procedures hve to be performed before ptient undergoes surgery in order to decrese the risk of infection. According to severl studies, chlorhexidine or povidone iodine re the most effective gents for skin disinfection [7,11,15,17]. Use of povidone iodine hs the development of hypothyroïdism s min risk fctor. Chlorhexidine (0.5% chlorhexidine +70% Iso-propnol) seems to be better choice becuse of its very low incidence of llergic rections, the bsence of ny importnt systemic effects [4] nd its residul ctivity. According to the study of Ayliffe et l. chlorhexidinedetergent consistently showed the best residul ctivity [13]. In our study we divided shunt infection into VCR-tppingrelted nd surgery-relted infections. VCR-tpping relted infections (n = 10) might be influenced by the frequency of VCR-tpping nd the septic techniques used [3]. Possible fctors relting to the surgicl infections (n = 10) mentioned in the literture re, segregtion of sterile mterils ( skin nd nonskin instruments ), the use of prophylctic ntibiotics, experience of the neurosurgeon nd durtion of the surgicl intervention [11]. The low number of infections per surgeon in our study does not llow comprison. No strict segregtion of skin nd non-skin instruments ws used. In the literture much controversy exists concerning the role of prophylctic ntibiotics in the prevention of shunt infections [11,18,19]. In our study, 33.3% of the opertions in which prophylctic ntibiotics were not used, were infected, wheres with prophylctic ntibiotics, the infection rte ws 13.9% per surgicl intervention. In our opinion this emphsizes the importnce of the use of prophylctic ntibiotics. In ddition, our results stress the necessity to reconsider the choice of ntibiotics. The combintion mostly used (rifmpicin nd flucloxcillin) showed the highest infection rte (19.7%). However, with vncomycin, dministered intrvenously nd/or intrtheclly, (when possible, using previously plced VCR) lone or in combintion with other gents (rifmpicin, ceftzidime, dministered intrvenously) no infections were found. Becuse the most frequently isolted microorgnism ws S. epidermidis, the best combintion to use seems to be vncomycin (dministered intrvenously nd/or intrtheclly) nd intrvenous rifmpicin. However, the use of rifmpicin s prophylxis should be voided, s, since the incresing resistnce of Stphylococcus ureus it hs to be preserved for therpeutic use only. Becuse decresed susceptibility to vncomycin hs lso recently been described in S. epidermidis [20], creful dherence to the prophylxis protocol, i.e. 24 h is of the utmost importnce. Also complince with the infection control progmme will help to reduce the prevlence of hospitl-cquired infections. The study of Fillce et l. presents useful dvice on diminishing the number of infections originting during surgery. This No-Touch Technique protocol gives meticulous tten-

5 206 Clinicl Microbiology nd Infection, Volume 6 Number 4, April 2000 tion to not touching the skin incision edges with shunt components to void bcteril contmintion of the shunt. Its use resulted in cliniclly significnt three-fold decrese in shunt infection rte per opertion (9.1 to 2.9%) [7]. In conclusion, premturity is n importnt risk fctor in reltion to shunt infections. In prticulr, ptients with PMA of less thn 37 weeks t their initil shunt plcement nd ELBWI, hve high risk for infection. In terms of infection the plcement of VCR in preterm infnts is vlid temporry mesure. In our opinion, the use of prophylctic ntibiotics nd optiml infection control mesures (pre-, per- nd postopertive) re necessry to keep the rte of infection s low s possible. The use of chlorhexidine skin preprtion nd prophylctic regime of vncomycin, dministered intrvenously nd/or intrtheclly, is recommended. REFERENCES 1 Ershin Y, Mutluer S, Guzelbg E. Cerebrospinl fluid shunt infections. J Neurosurg Sciences 1994; 38: Kontny U, Hofling B, Gutjhr P, Voth D, Schwrz M, Schmitt HJ. CSF shunt infections in children. Infection 1993; 21: Benzel EC, Reeves JP, Nguyen PhK, Hdden ThA. The tretment of hydrocephlus in preterm infnts with intrventriculr hemorrhge. Act Neurochir 1993; 122: Pople IK, Byston R, Hywrd RD. Infection of cerebrospinl fluid shunts in infnts: study of etiologicl fctors. J Neurosurg 1992; 77: Borgbjerg BM, Gjerris F, Albeck MJ, Borgesen SE. Risk of infection fter cerebrospinl fluid shunt: n nlysis of 884 first-time shunts. Act Neurochir 1995; 136: Hoekstr MO, Hoorntje TM, Alderen v WMC. Shuntmeningitis: een herkenbr klinisch beeld. Ned Tijdschrift Geneeskd 1988; 11: Fillce WJ. A No-Touch Technique protocol to diminish cerebrospinl fluid shunt infection. Surg Neurol 1995; 43: Schiff SJ, Okes WJ. Delyed cerebrospinl fluid shunt infection in children. Peditric Neurosci 1989; 15: Lngley JM, LeBlnc JC, Drke J, Milner R. Efficicy of ntimicrobil prophylxis in plcement of cerebrospinl fluid shunts: met-nlysis. Clin Infect Dis 1993; 17: Boynton BR, Boynton CA, Merritt TA, Vucher YE, Jmes HE. Ventriculoperitonel shunts in low birth weight infnts with intrcrnil hemorrhge. Neurodevelopmentl Outcome Neurosurgery 1986; 18: Choux M, Genitori L, Lng D, Len G. Shunt implnttion: reducing the incidence of shunt infection. J Neurosurg 1997; 77: Willims DG, Hyes J, McCool S. Shunt infection in children: presenttion nd mngment. J Neurosci Nursing 1996; 28: Ayliffe GAJ, Bbb JR, Dvies JG, Lilly HA. Hnd disinfection: comprison of vrious gents in lbortory nd wrd studies. J Hosp Infect 1988; 11: Renier D, Lcombe J, Pierre-Khn A et l. Fctors cusing cute shunt infection: computer nlysis of 1174 opertions. J Neurosurg 1984; 61: Strombld L-G, Schlen C, Steen A, Sundbrg G, Kmm C. Bcteril contmintion in cerebrospinl fluid shunt surgery. Scnd J Infect Dis 1987; 19: Gvilnes AWD, Heinemn E, Herpers MJHM, Blnco CE. Use of neontl intensive cre unit s sfe plce for neontl surgery. Arch Dis Child 1997; 76: F51 F Rotim K, Miklic P, Pldino J, Meld A, Mrcikic M, Scp M. Reducing the incidence of infection in peditric cerebrospinl fluid shunt opertions. Child s Nerv Syst 1997; 1997: Brown EM, Louvois J, Byston R, Hedges AJ, Johnston RA, Lees P. Antimicrobil prophylxis in neurosurgery nd fter hed injury. Lncet 1994; 344: Hines SJ, Wlter BC. Antibiotic prophylxis for cerebrospinl fluid shunts: met-nlysis. Neurosurgery 1994; 34: Grret DO, Jochimsen E, Murfitt K et l. The emergence of decresed susceptibility to vncomycin in Stphylococcus epidermidis. Infect Control Hosp Epidemiol 1999; 20: