title: Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants.
abstract: OBJECTIVE
  Intraventricular hemorrhage in premature infants often leads to progressive ventricular dilation and the need for ventricular reservoir placement. Unfortunately, these reservoirs have a higher rate of infection than ventriculoperitoneal shunts in premature babies. The authors analyzed the risk factors for infection in this population and studied whether the implementation of an institutional protocol for shunt placement had a corollary effect on ventricular access device (VAD) infection rates in premature neonates with intraventricular hemorrhage.
  
  
  METHODS
  The authors conducted a retrospective cohort review of consecutive premature neonates in whom VADs were inserted in the operating room at Primary Children's Hospital between June 2003 and June 2011 to identify risk factors for infection. Medical records were reviewed for information on infection (culture proven or eroded hardware at 90 days), gestational age at birth, weight, gestational age at surgery, intrathecal antibiotics, hemorrhage, death, and surgeon. The institution used a pilot protocol for shunt infection reduction in 2006-2007, and then the full Hydrocephalus Clinical Research Network protocol from June 2007 to 2011, and the rates of infection during these periods were analyzed. Confounding factors such as sepsis, necrotizing enterocolitis, and a history of meningitis were also analyzed.
  
  
  RESULTS
  The overall infection rate was 10.5% (11 patients) in the 105 patients identified. Gestational age at procedure was a significant risk factor for infection (p=0.05). Meningitis was significantly associated with infection, with 63% of the infected group having had prior meningitis compared with 7% for the noninfected group (p<0.001). Concurrent with the implementation of the protocol to reduce shunt infection, the VAD infection rate decreased from 14.7% to 5.4% (p=0.2).
  
  
  CONCLUSIONS
  Gestational age at procedure and previous meningitis were significant risk factors for VAD infections. In addition, the implementation of an institutional standardized shunt protocol for ventriculoperitoneal shunts may have altered the operating room team's behavior, indicated by a nonmandated use of intrathecal antibiotics in VAD surgeries, contributing to a reduced VAD infection rate. Although the observed difference was not statistically significant with the small sample size, the authors believe that these findings deserve further study.
authors.affiliation: Department of Neurosurgery, Rhode Island Hospital, Brown University, Providence, Rhode Island;
authors.forename: Heather S
authors.initials: HS
authors.lastname: Spader
authors.forename: Dean A
authors.initials: DA
authors.lastname: Hertzler
authors.forename: John R W
authors.initials: JR
authors.lastname: Kestle
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
mesh_terms: D002985:Clinical Protocols / Q000592:standards; D005260:Female; D005865:Gestational Age; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007234:Infant, Premature; D007239:Infections / Q000453:epidemiology* / Q000209:etiology*; D008297:Male; D008581:Meningitis / Q000150:complications; D012189:Retrospective Studies; D012307:Risk Factors; D014589:Utah / Q000453:epidemiology; D017287:Ventriculoperitoneal Shunt / Q000009:adverse effects*
keywords: HCRN = Hydrocephalus Clinical Research Network; IT = intrathecal; IVH = intraventricular hemorrhage; NEC = necrotizing enterocolitis; PCH = Primary Children's Hospital; PPHVD = progressive posthemorrhagic ventricular dilation; VAD = ventricular access device; VP = ventriculoperitoneal; hydrocephalus; infection; ventricular access device; ventricular hemorrhage