title: Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection.
abstract: OBJECTIVE
  The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus?
  
  
  METHODS
  The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I-III).
  
  
  RESULTS
  A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).
  
  
  CONCLUSIONS
  Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.
  
  
  CONCLUSIONS
  Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection.
  
  
  METHODS
  Level II, moderate degree of clinical certainty.
  
  
  CONCLUSIONS
  There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required.
  
  
  METHODS
  Level III, unclear degree of clinical certainty.
  
  
  CONCLUSIONS
  There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.
  
  
  METHODS
  Level III, unclear degree of clinical certainty.
authors.affiliation: Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Tamber
authors.affiliation: Department of Neurosurgery, University of Tennessee Health Science Center, Memphis|3Le Bonheur Children's Hospital, Memphis, Tennessee;
authors.forename: Paul
authors.initials: P
authors.lastname: Klimo
authors.affiliation: Division of Pediatric Neurological Surgery, Goryeb Children's Hospital, Morristown, New Jersey
authors.forename: Catherine A
authors.initials: CA
authors.lastname: Mazzola
authors.affiliation: Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri
authors.forename: Ann Marie
authors.initials: AM
authors.lastname: Flannery
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects*; D002648:Child; D020878:Device Removal; D019317:Evidence-Based Medicine; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D007239:Infections / Q000188:drug therapy / Q000209:etiology / Q000628:therapy*; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control / Q000628:therapy*; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents
keywords: EVD = external ventricular drain; VA = ventriculoatrial; VP = ventriculoperitoneal; cerebrospinal fluid shunt; evidence-based guidelines; hydrocephalus; infection; pediatrics; practice guidelines; therapy