title: A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection.
abstract: OBJECT In a previous report by the same research group (Kestle et al., 2011), compliance with an 11-step protocol was shown to reduce CSF shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. METHODS The new protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Procedures performed up to September 30, 2013, were included (21 months). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 1935 procedures were performed on 1670 patients at 8 HCRN centers. The overall infection rate was 6.0% (95% CI 5.1%-7.2%). Procedure-specific infection rates varied (insertion 5.0%, revision 5.4%, insertion after EVD 8.3%, and insertion after treatment of infection 12.6%). Full compliance with the protocol occurred in 77% of procedures. The infection rate was 5.0% after compliant procedures and 8.7% after noncompliant procedures (p = 0.005). The infection rate when using this new protocol (6.0%, 95% CI 5.1%-7.2%) was similar to the infection rate observed using the authors' old protocol (5.7%, 95% CI 4.6%-7.0%). CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRN centers had a lower infection rate than noncompliant procedures. Implementation of the new protocol (including AICs) was associated with a 6.0% infection rate, similar to the infection rate of 5.7% from the authors' previously reported protocol. Based on the current data, the role of AICs compared with other infection prevention measures is unclear.
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
authors.forename: John R W
authors.initials: JR
authors.lastname: Kestle
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
authors.forename: Richard
authors.initials: R
authors.lastname: Holubkov
authors.affiliation: Division of Pediatric Neurosurgery, British Columbia Children's Hospital, Vancouver, British Columbia.
authors.forename: D
authors.initials: D
authors.lastname: Douglas Cochrane
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada;
authors.forename: Abhaya V
authors.initials: AV
authors.lastname: Kulkarni
authors.affiliation: Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri;
authors.forename: David D
authors.initials: DD
authors.lastname: Limbrick
authors.affiliation: Department of Neurosurgery, Texas Children's Hospital, Houston, Texas;
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.affiliation: Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama;
authors.forename: W
authors.initials: W
authors.lastname: Jerry Oakes
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
authors.forename: Jay
authors.initials: J
authors.lastname: Riva-Cambrin
authors.affiliation: Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama;
authors.forename: Curtis
authors.initials: C
authors.lastname: Rozzelle
authors.affiliation: Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington;
authors.forename: Tamara D
authors.initials: TD
authors.lastname: Simon
authors.affiliation: Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
authors.forename: Marion L
authors.initials: ML
authors.lastname: Walker
authors.affiliation: Department of Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; and.
authors.forename: John C
authors.initials: JC
authors.lastname: Wellons
authors.affiliation: Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington;
authors.forename: Samuel R
authors.initials: SR
authors.lastname: Browd
authors.affiliation: Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada;
authors.forename: James M
authors.initials: JM
authors.lastname: Drake
authors.affiliation: Department of Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; and.
authors.forename: Chevis N
authors.initials: CN
authors.lastname: Shannon
authors.affiliation: Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.
authors.forename: Mandeep S
authors.initials: MS
authors.lastname: Tamber
authors.affiliation: Department of Neurosurgery, Texas Children's Hospital, Houston, Texas;
authors.forename: William E
authors.initials: WE
authors.lastname: Whitehead
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D055499:Catheter-Related Infections / Q000453:epidemiology / Q000517:prevention & control*; D002408:Catheters, Indwelling / Q000592:standards* / Q000706:statistics & numerical data; D002557:Cerebrospinal Fluid Shunts / Q000592:standards* / Q000706:statistics & numerical data; D002648:Child; D002985:Clinical Protocols / Q000592:standards*; D006801:Humans; D006849:Hydrocephalus / Q000453:epidemiology / Q000601:surgery*; D012086:Reoperation / Q000706:statistics & numerical data
chemical_list: D000900:Anti-Bacterial Agents
keywords: AIC = antibiotic-impregnated catheter; EVD = external ventricular drain; HCRN = Hydrocephalus Clinical Research Network; cerebrospinal fluid; hydrocephalus; protocol; quality improvement; shunt infection