title: Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study.
abstract: OBJECTIVE
  To quantify the extent to which cerebrospinal fluid (CSF) shunt revisions are associated with increased risk of CSF shunt infection, after adjusting for patient factors that may contribute to infection risk.
  
  
  METHODS
  We used the Hydrocephalus Clinical Research Network registry to assemble a large prospective 6-center cohort of 1036 children undergoing initial CSF shunt placement between April 2008 and January 2012. The primary outcome of interest was first CSF shunt infection. Data for initial CSF shunt placement and all subsequent CSF shunt revisions prior to first CSF shunt infection, where applicable, were obtained. The risk of first infection was estimated using a multivariable Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HRs) with 95% CI.
  
  
  RESULTS
  Of the 102 children who developed first infection within 12 months of placement, 33 (32%) followed one or more CSF shunt revisions. Baseline factors independently associated with risk of first infection included: gastrostomy tube (HR 2.0, 95% CI, 1.1, 3.3), age 6-12 months (HR 0.3, 95% CI, 0.1, 0.8), and prior neurosurgery (HR 0.4, 95% CI, 0.2, 0.9). After controlling for baseline factors, infection risk was most significantly associated with the need for revision (1 revision vs none, HR 3.9, 95% CI, 2.2, 6.5; ≥2 revisions, HR 13.0, 95% CI, 6.5, 24.9).
  
  
  CONCLUSIONS
  This study quantifies the elevated risk of infection associated with shunt revisions observed in clinical practice. To reduce risk of infection risk, further work should optimize revision procedures.
authors.affiliation: Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA. Electronic address: Tamara.Simon@seattlechildrens.org.
authors.forename: Tamara D
authors.initials: TD
authors.lastname: Simon
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, UT.
authors.forename: Jeremiah
authors.initials: J
authors.lastname: Butler
authors.affiliation: Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA.
authors.forename: Kathryn B
authors.initials: KB
authors.lastname: Whitlock
authors.affiliation: Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, WA.
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Browd
authors.affiliation: Department of Pediatrics, University of Utah, Salt Lake City, UT.
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT.
authors.forename: John R W
authors.initials: JR
authors.lastname: Kestle
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada.
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT.
authors.forename: Marcie
authors.initials: M
authors.lastname: Langley
authors.affiliation: Department of Neurosurgery, St Louis Children's Hospital, Washington University in Saint Louis, St Louis, MO.
authors.forename: David D
authors.initials: DD
authors.lastname: Limbrick
authors.affiliation: Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Mayer-Hamblett
authors.affiliation: Division of Neurosurgery, Children's Hospital of Pittsburgh, Pittsburgh, PA.
authors.forename: Mandeep
authors.initials: M
authors.lastname: Tamber
authors.affiliation: Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Birmingham, AL.
authors.forename: John C
authors.initials: JC
authors.lastname: Wellons
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
authors.affiliation: Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT.
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
mesh_terms: D000293:Adolescent; D017677:Age Distribution; D001424:Bacterial Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D002555:Cerebrospinal Fluid / Q000382:microbiology*; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects* / Q000379:methods; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006849:Hydrocephalus / Q000175:diagnosis / Q000601:surgery; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012042:Registries; D012086:Reoperation / Q000379:methods; D017678:Sex Distribution; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000453:epidemiology* / Q000601:surgery; D016896:Treatment Outcome