Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Harrop, James S.; Sharan, Ashwini; Ratliff, John K.; Prasad, Srini; Jabbour, Pascal; Evans, James J.; Veznedaroglu, Erol; Andrews, David W.; Maltenfort, Mitchell; Liebman, Kenneth; Flomenberg, Phyllis; Sell, B.; Baranoski, Amy S.; Fonshell, Claudette; Reiter, David; Rosenwasser, Robert H.

doi:10.1227/01.neu.0000370247.11479.b6

Cited by 72 publications

(47 citation statements)

References 34 publications

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“…The reduction in VRIs to 4.3% after introduction of ac-EVDs is similar to the rates seen in other retrospective and prospective studies of ac-EVDs use, where infection rates were decreased to 0.9%-5% per EVD. 3,[6][7][8]13,15,16,18 However, studies differ in terms of how they define a VRI and also by the presence of prolonged antibiotic prophylaxis, making direct comparisons with our study difficult. Zabramski et al, 20 for example, reported results from a 6-center randomized clinical trial in which minocycline and rifampin ac-EVDs were compared with conventional EVDs, and almost all patients received PSA throughout the EVD placement period.…”

Section: Discussionmentioning

confidence: 90%

Rates and determinants of ventriculostomy-related infections during a hospital transition to use of antibiotic-coated external ventricular drains

Wright

Young

Brickman

et al. 2013

FOC

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Object The authors evaluated the rates of ventriculostomy-related infections (VRIs) after antibiotic-coated extraventricular drains (ac-EVDs) were introduced as the standard of care. Methods A retrospective chart review was conducted of adult patients admitted to NewYork-Presbyterian Hospital neurological intensive care unit in whom an EVD was placed between February 2007 and November 2009, excluding individuals receiving EVDs due to an infection of a primary device. Three time periods were defined depending on type of EVD in use: Period 1, conventional EVDs; Period 2, either ac-EVDs or conventional EVDs; and Period 3, ac-EVDs. Definite/probable VRIs that occurred during the 3 periods were evaluated and established as determinants of VRIs by using a Cox proportional hazards model. Prolonged systemic antibiotics were given for the duration of EVD placement in each of the 3 periods per institutional policy. Results Data from 141 individuals were evaluated; mean patient age was 53.8 ± 17.2 years and 54% were female. There were 2 definite and 19 probable VRIs. The incidence of definite/probable VRI (per 1000 person-catheter days) decreased from Period 1 to 3 (24.5, 16.2, and 4.4 in Periods 1, 2, and 3, respectively; p < 0.0001). Patients with VRIs were more likely to be female than male (23.7% vs 3.1%, p < 0.003) and have had an EVD in place for a longer duration, although there was no significant difference among the 3 periods (7.9 ± 6.7 [Period 1], 8.1 ± 7.1 [Period 2], and 8.6 ± 5.8 [Period 3] mean days; p = 0.87, ANOVA). Analysis of effect modification in a stepwise model showed that period, age, and age and female interaction were significant predictors of VRIs. The period was the strongest predictor of VRI (p = 0.0075). After adjustment for age and age and sex interaction, the survival rate was 53% at the end of Period 2 and 91% at the end of Period 3. Conclusions Rates of VRIs have decreased with the addition of ac-EVDs to the routine use of prolonged systemic antibiotics at the authors' institution.

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Section: Discussionmentioning

confidence: 90%

Rates and determinants of ventriculostomy-related infections during a hospital transition to use of antibiotic-coated external ventricular drains

Wright

Young

Brickman

et al. 2013

FOC

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“…This finding might be related to the local care of the ventriculostomy site, as well as the use of antibioticimpregnated ventriculostomy catheters in all patients in the present study, which likely reduced contamination of ventriculostomy sites. Indeed, Harrop et al 6 reported a dramatic decrease in ventriculostomy infection rates from 6.7% to 0.9% after introduction of antibiotic-impregnated catheters. The findings of our study are in line with those of Rammos et al, 15 who reported no shunt infections during the follow-up period (mean 24 months) in 80 patients undergoing conversion of a ventriculostomy to a VPS using the same ventriculostomy site.…”

Section: Discussionmentioning

confidence: 99%

“…For a VPS placed using a fresh contralateral site, the standard technique was used as previously described in the literature. [2][3][4][5][6] All wounds were copiously irrigated with normal saline. Head CT scanning and a shunt series were performed for all patients within 24 hours after VPS placement to confirm adequate catheter position and decompression of the ventricular system and to identify procedural complications.…”

Section: Same-site Vps Techniquementioning

confidence: 99%

Comparison of techniques for ventriculoperitoneal shunting in 523 patients with subarachnoid hemorrhage

Chalouhi

Whiting

Anderson

et al. 2014

JNS

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A cute hydrocephalus occurs in up to two-thirds of patients with subarachnoid hemorrhage (SAH), and its treatment involves the placement of a ventriculostomy catheter. 7,10,12,14 Around 6%-37% of patients ultimately require permanent CSF diversion usually treated through ventriculoperitoneal shunt (VPS) placement because of the development of chronic hydrocephalus. [3][4][5]14 It is common practice to use a new contralateral bur hole for placement of the VPS in SAH patients with an existing ventriculostomy. The classic reasoning behind this practice is that the potential, subclinical contamination of the ventriculostomy site may increase the risk of shunt infection. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, we have primarily used the same ventriculostomy site for placement of the VPS. This technique provides atraumatic insertion of the ventricular catheter without the stylet through an existing track while potentially decreasing the risk of catheter-related hemorrhage or malpositioning and reducing the operative time.Practice in this respect, both in the US and abroad, has largely been driven by operator preference and experience, as little has been published about the optimal shunting technique. We present the results of the first study comparing the safety of the 2 VPS techniques (same site vs contralateral site) in patients with SAH. Object. It is common practice to use a new contralateral bur hole for ventriculoperitoneal shunt (VPS) placement in subarachnoid hemorrhage (SAH) patients with an existing ventriculostomy. At Thomas Jefferson University and Jefferson Hospital for Neuroscience, the authors have primarily used the ventriculostomy site for the VPS. The purpose of this study was to compare the safety of the 2 techniques in patients with SAH.Methods. The rates of VPS-related hemorrhage, infection, and proximal revision were compared between the 2 techniques in 523 patients undergoing VPS placement (same site in 464 and contralateral site in 59 patients).Results. The rate of new VPS-related hemorrhage was significantly higher in the contralateral-site group (1.7%) than in the same-site group (0%; p = 0.006). The rate of VPS infection did not differ between the 2 groups (6.4% for same site vs 5.1% for contralateral site; p = 0.7). In multivariate analysis, higher Hunt and Hess grades (p = 0.05) and open versus endovascular treatment (p = 0.04) predicted shunt infection, but the VPS technique was not a predictive factor (p = 0.9). The rate of proximal shunt revision was 6% in the same-site group versus 8.5% in the contralateralsite group (p = 0.4). In multivariate analysis, open surgery was the only factor predicting proximal VPS revision (p = 0.05).Conclusions. The results of this study suggest that the use of the ventriculostomy site for VPS placement may be feasible and safe and may not add morbidity (infection or need for revision) compared with the use of a fresh contralateral site. This rapid and simple technique also was associated with a lower risk of shunt-related h...

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“…49 Furthermore, Harrop et al described a prospective cohort study in which the introduction of AI-EVDs decreased the VAI rate from 8.2% to 1%. 28 Interestingly, the VAI rate increased to 7.6% when the institution reverted to standard catheters due to technical problems with the AI-EVDs; however, when the AI-EVDs were reintroduced, the VAI rate decreased to 0.9%. 28 Based on the available evidence and selected studies above, there seems to be a trend toward decreased rates of VAI with AI-EVDs.…”

Section: Complications Of Invasive Intracranial Pressure Monitoring Dmentioning

confidence: 98%

“…28 Interestingly, the VAI rate increased to 7.6% when the institution reverted to standard catheters due to technical problems with the AI-EVDs; however, when the AI-EVDs were reintroduced, the VAI rate decreased to 0.9%. 28 Based on the available evidence and selected studies above, there seems to be a trend toward decreased rates of VAI with AI-EVDs. To this end, the 2016 Neurocritical Care Society consensus statement on neuromonitoring recommended the use of AI-EVDs, and the Brain Trauma Foundation 4th edition guidelines provided a Level III recommendation for the use of AI-EVDs to prevent VAIs.…”

Section: Complications Of Invasive Intracranial Pressure Monitoring Dmentioning

confidence: 98%

Complications of invasive intracranial pressure monitoring devices in neurocritical care

Tavakoli¹,

Peitz²,

Ares

et al. 2017

Neurosurgical Focus

142

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Intracranial pressure monitoring devices have become the standard of care for the management of patients with pathologies associated with intracranial hypertension. Given the importance of invasive intracranial monitoring devices in the modern neurointensive care setting, gaining a thorough understanding of the potential complications related to device placement—and misplacement—is crucial. The increased prevalence of intracranial pressure monitoring as a management tool for neurosurgical patients has led to the publication of a plethora of papers regarding their indications and complications. The authors aim to provide a concise review of key contemporary articles in the literature concerning important complications with the hope of elucidating practices that improve outcomes for neurocritically ill patients.

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Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients

Abstract: The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

Cited by 72 publications

References 34 publications

Rates and determinants of ventriculostomy-related infections during a hospital transition to use of antibiotic-coated external ventricular drains

Rates and determinants of ventriculostomy-related infections during a hospital transition to use of antibiotic-coated external ventricular drains

Comparison of techniques for ventriculoperitoneal shunting in 523 patients with subarachnoid hemorrhage

Complications of invasive intracranial pressure monitoring devices in neurocritical care

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