title: Primary ventriculoperitoneal shunting outcomes: a multicentre clinical audit for shunt infection and its risk factors.
abstract: OBJECTIVE
  To determine the frequency of primary ventriculoperitoneal shunt infection among patients treated at neurosurgical centres of the Hospital Authority and to identify underlying risk factors.
  
  
  METHODS
  This multicentre historical cohort study included consecutive patients who underwent primary ventriculoperitoneal shunting at a Hospital Authority neurosurgery centre from 1 January 2009 to 31 December 2011. The primary endpoint was shunt infection, defined as: (1) the presence of cerebrospinal fluid or shunt hardware culture that yielded the pathogenic micro-organism with associated compatible symptoms and signs of central nervous system infection or shunt malfunction; or (2) surgical incision site infection requiring shunt reinsertion (even in the absence of positive culture); or (3) intraperitoneal pseudocyst formation (even in the absence of positive culture). Secondary endpoints were shunt malfunction, defined as unsatisfactory cerebrospinal fluid drainage that required shunt reinsertion, and 30-day mortality.
  
  
  RESULTS
  A primary ventriculoperitoneal shunt was inserted in 538 patients during the study period. The mean age of patients was 48 years (range, 13-88 years) with a male-to-female ratio of 1:1. Aneurysmal subarachnoid haemorrhage was the most common aetiology (n=169, 31%) followed by intracranial tumour (n=164, 30%), central nervous system infection (n=42, 8%), and traumatic brain injury (n=27, 5%). The mean operating time was 75 (standard deviation, 29) minutes. Shunt reinsertion and infection rates were 16% (n=87) and 7% (n=36), respectively. The most common cause for shunt reinsertion was malfunction followed by shunt infection. Independent predictors for shunt infection were: traumatic brain injury (adjusted odds ratio=6.2; 95% confidence interval, 2.3-16.8), emergency shunting (2.3; 1.0-5.1), and prophylactic vancomycin as the sole antibiotic (3.4; 1.1-11.0). The 30-day all-cause mortality was 6% and none were directly procedure-related.
  
  
  CONCLUSIONS
  This is the first Hong Kong territory-wide review of infection in primary ventriculoperitoneal shunts. Although the ventriculoperitoneal shunt infection rate met international standards, there are areas of improvement such as vancomycin administration and the avoidance of scheduling the procedure as an emergency.
authors: Department of Neurosurgery, Kwong Wah Hospital, Yaumatei, Hong Kong.
authors: P Ym
authors: PY
authors: Woo
authors: Department of Neurosurgery, Kwong Wah Hospital, Yaumatei, Hong Kong.
authors: H T
authors: HT
authors: Wong
authors: Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Pokfulam, Hong Kong.
authors: J Ks
authors: JK
authors: Pu
authors: Department of Neurosurgery, Princess Margaret Hospital, Laichikok, Hong Kong.
authors: W K
authors: WK
authors: Wong
authors: Department of Neurosurgery, Queen Elizabeth Hospital, Jordan, Hong Kong.
authors: L Yw
authors: LY
authors: Wong
authors: Department of Neurosurgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.
authors: M Wy
authors: MW
authors: Lee
authors: Department of Neurosurgery, Tuen Mun Hospital, Tuen Mun, Hong Kong.
authors: K Y
authors: KY
authors: Yam
authors: Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, Pokfulam, Hong Kong.
authors: W M
authors: WM
authors: Lui
authors: Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong.
authors: W S
authors: WS
authors: Poon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D015331:Cohort Studies; D004868:Equipment Failure; D005260:Female; D006723:Hong Kong; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000453:epidemiology*; D014640:Vancomycin / Q000008:administration & dosage*; D017287:Ventriculoperitoneal Shunt; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D014640:Vancomycin
keywords: Clinical audit; Risk factors; Ventriculoperitoneal shunt