Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The objective of this systematic review and meta-analysis was twofold: to answer the question “What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?” and to make treatment recommendations based on the available evidence.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I<jats:sup>2</jats:sup> statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38–0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).</jats:p></jats:sec> <jats:sec> <jats:title>Recommendation</jats:title> <jats:p>The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection. S<jats:sc>trength of</jats:sc> R<jats:sc>ecommendation</jats:sc>: Level II, moderate degree of clinical certainty.</jats:p></jats:sec>

Topical vancomycin reduces the cerebrospinal fluid shunt infection rate: A retrospective cohort study

“…Many efforts have been taken to reduce the shunt infection rate. Preoperative intravenous (iv) prophylactic antibiotics are administered routinely and this is a mainstay of prevention [ 10 ]. Many different measures appear to contribute to reducing the shunt infection rate, although evidence for each separate measure is minimal or nonexistent [ 11 ].…”

Characteristics and management of ventricular shunt infections in children, 2000-2015: a single centre retrospective chart review

“…One of the most important actions shown to reduce shunt infections is perioperative prophylactic antibiotics, with the literature supporting their use in all patients undergoing a shunt insertion 2,24 . A systematic review and meta-analysis by Ratilal et al demonstrated that antibiotic prophylaxis can significantly decrease the rate of shunt infection (OR 0.51, 95% CI 0.36-0.73) 25 .…”

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

“…El uso de antibiótico profiláctico sistémico es controversial; sin embargo, la evidencia actual halla un efecto benéfico de su administración con la reducción de las tasas de infección postoperatoria, que varía desde un 20 % hasta un 50 % (43) . Igualmente, sugiere la fuga de LCR como el principal factor de riesgo para la infección, por lo que si persiste por más de 7 días debería considerarse el manejo quirúrgico (31,(44)(45)(46)(47)(48)(49)(50)(51) . En intervenciones quirúrgicas como el drenaje ventricular externo se requiere ampliar la evidencia, especialmente en sí es útil la administración continúa hasta el retiro del catéter (31,49) .…”

“…Los regímenes de antibióticos usados en los diferentes estudios no son homogéneos. Dentro de estos, se incluyen el uso de vancomicina, oxacilina, clindamicina, cefazolina, trimetoprim sulfametoxazol, ampicilina y cefalosporinas de tercera generación, los cuales cumplen fundamentalmente con el cubrimiento de microorganismos grampositivos, teniendo en cuenta que el principal agente involucrado es el Staphylococcus spp (31,(44)(45)(46)(47)(48)(49)(50)(51)(52)53) . Algunos estudios han favorecido el uso de vancomicina, especialmente en contextos de alta prevalencia de SAMR, pero otros no han encontrado diferencias entre esquemas (53,54,55) .…”