title: Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure.
abstract: OBJECTIVE
  The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.
  
  
  METHODS
  This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.
  
  
  RESULTS
  A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively).
  
  
  CONCLUSIONS
  This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.
authors.affiliation: Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida;
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Beckman
authors.affiliation: Department of Clinical and Translational Research and.|Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Ernest K
authors.initials: EK
authors.lastname: Amankwah
authors.affiliation: Department of Clinical and Translational Research and.|Neuroscience Institute, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg, Florida; and.
authors.forename: Lisa L
authors.initials: LL
authors.lastname: Tetreault
authors.affiliation: Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, Florida;|Neuroscience Institute, All Children's Hospital/Johns Hopkins Medicine, St. Petersburg, Florida; and.|Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
authors.forename: Gerald F
authors.initials: GF
authors.lastname: Tuite
mesh_terms: D000293:Adolescent; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis / Q000379:methods; D001414:Bacitracin / Q000008:administration & dosage*; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005431:Florida / Q000453:epidemiology; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery; D015994:Incidence; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D011208:Powders; D012086:Reoperation / Q000009:adverse effects; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000891:Anti-Infective Agents, Local; D011208:Powders; D001414:Bacitracin
keywords: ASA = American Society of Anesthesiologists; GMH = germinal matrix hemorrhage; GT = gastrostomy tube; HCRN = Hydrocephalus Clinical Research Network; HR = hazard ratio; antibiotic; bacitracin; cerebrospinal fluid; hydrocephalus; infection; powder