title: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis.
abstract: OBJECTIVE
  The objective of this systematic review and meta-analysis was twofold: to answer the question "What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?" and to make treatment recommendations based on the available evidence.
  
  
  METHODS
  The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).
  
  
  RESULTS
  Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).
  
  
  CONCLUSIONS
  The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.
  
  
  METHODS
  Level II, moderate degree of clinical certainty.
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center|3Le Bonheur Children's Hospital, Memphis, Tennessee;
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center|3Le Bonheur Children's Hospital, Memphis, Tennessee;
authors.forename: Mark
authors.initials: M
authors.lastname: Van Poppel
authors.affiliation: School of Public Health and Health Services, The George Washington University, Washington, DC
authors.forename: Clinton J
authors.initials: CJ
authors.lastname: Thompson
authors.forename: Lissa C
authors.initials: LC
authors.lastname: Baird
authors.affiliation: Department of Pediatric Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
authors.forename: Ann-Christine
authors.initials: AC
authors.lastname: Duhaime
authors.affiliation: Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri
authors.forename: Ann Marie
authors.initials: AM
authors.lastname: Flannery
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects*; D002648:Child; D019317:Evidence-Based Medicine; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D057234:Preoperative Period; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents
keywords: AANS = American Association of Neurological Surgeons; CNS = Congress of Neurological Surgeons; RCT = randomized controlled trial; RR = risk ratio; VP = ventriculoperitoneal; antibiotics; cerebrospinal fluid; evidence-based guidelines; hydrocephalus; infection; intravenous; meta-analysis; pediatrics; periopcrativc; practice guidelines; preoperative; shunt