title: A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections.
abstract: BACKGROUND
  Ventriculostomy insertion is a common neurosurgical intervention and can be complicated by ventriculostomy-associated cerebrospinal fluid infection (VAI) which is associated with increased morbidity and mortality. This meta-analysis was aimed at determining the pooled incidence rate (number per 1000 catheter-days) of VAI.
  
  
  METHODS
  Relevant studies were identified from MEDLINE and EMBASE and from reference searching of included studies and recent review articles on relevant topics. The Newcastle-Ottawa Scale was used to assess quality and risk of bias. A random effects model was used to pool individual study estimates and 95% confidence intervals (CI) were calculated using the exact Poisson method. Heterogeneity was assessed using the heterogeneity χ2 and I-squared tests. Subgroup analyses were performed and a funnel plot constructed to assess publication bias.
  
  
  RESULTS
  There were a total of 35 studies which yielded 752 infections from 66,706 catheter-days of observation. The overall pooled incidence rate of VAI was 11.4 per 1000 catheter days (95% CI 9.3 to 13.5), for high quality studies the rate was 10.6 (95% CI 8.3 to 13) and 13.5 (95% CI 8.9 to 18.1) for low quality studies. Studies which had mean duration of EVD treatment of less than 7 days had a pooled VAI rate of 19.6 per 1000 catheter-days, those with mean duration of 7-10 days had VAI rate of 12.8 per 1000 catheter-days and those with mean duration greater than 10 days had VAI rate of 8 per 1000 catheter-days. There was significant heterogeneity for the primary outcome (p = 0.004, I-squared = 44%) and most subgroups. The funnel plot did not show evidence for publication bias.
  
  
  CONCLUSIONS
  The incidence rate of VAI is 11.4 per 1000 catheter-days. Further research should focus on analysis of risk factors for VAI and techniques for reducing the rate of VAI.
authors.affiliation: Burns Trauma Critical Care Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia. ramanan.mahesh@gmail.com.|Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, 4029, Australia. ramanan.mahesh@gmail.com.
authors.forename: Mahesh
authors.initials: M
authors.lastname: Ramanan
authors.affiliation: Burns Trauma Critical Care Research Centre, School of Medicine, University of Queensland, Brisbane, Queensland, Australia. j.lipman@uq.edu.au.|Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, 4029, Australia. j.lipman@uq.edu.au.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Lipman
authors.affiliation: Medical Intensive Care Unit, Washington Hospital Center, Washington, DC, USA. andrew.shorr@gmail.com.
authors.forename: Andrew
authors.initials: A
authors.lastname: Shorr
authors.affiliation: Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India. dr.aparna.83@gmail.com.
authors.forename: Aparna
authors.initials: A
authors.lastname: Shankar
mesh_terms: D002408:Catheters, Indwelling / Q000009:adverse effects*; D002494:Central Nervous System Infections / Q000453:epidemiology* / Q000209:etiology / Q000382:microbiology; D002555:Cerebrospinal Fluid / Q000382:microbiology*; D006801:Humans; D015994:Incidence; D014696:Ventriculostomy / Q000009:adverse effects*