Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases

Abstract

BACKGROUND External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. OBJECTIVE To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. METHODS We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. RESULTS Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. CONCLUSION Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.

Reduction of ventriculostomy-associated CSF infection with antibiotic-impregnated catheters in pediatric patients: a single-institution study

“…The EVD duration was significantly different among groups (Table 1); patients with an EVD placed for intracranial tumor had a significantly shorter EVD duration (median [IQR]: 4 [2-8] days) than those in the "other" group (median [IQR]: 7 [4][5][6][7][8][9][10][11][12]) days) (p = 0.0009).…”

“…Recently there has been an increase in the number of studies on placement of antibiotic-impregnated catheters in adult patients, with most but not all studies demonstrating a reduction in EVD-associated infections. 4,[7][8][9][10][11]13,16 In contrast, studies are very limited in the pediatric literature. In one recent study in which a prospective, multicenter analysis of EVD-related infections in the UK and Ireland were reported, the majority of the patients were adults in whom the type of catheter had no effect on the adult infection rate; of the 37 pediatric patients in the study, 3 had an infection (an infection rate of 8.1%), and 23 of the 37 pediatric patients had an antibiotic-impregnated catheter, but no information is given about whether the infection was associated with the type of catheter (antibiotic-impregnated, silver-impregnated, or nonantibiotic-impregnated).…”

“…Some studies in adults have demonstrated that the use of antibiotic-impregnated EVD catheters has decreased the EVD-associated infection rate, whereas others have not. 4,[7][8][9][10][11][12]16,17 Studies of antibiotic-impregnated EVD catheters are lacking in the pediatric population. In one small study, the use of antibiotic-impregnated EVD catheters in the management of hydrocephalus in children with posterior cranial fossa tumors demonstrated a decrease in CSF infection rate with the use of antibiotic-impregnated catheters compared to the rate in their historical control group.…”

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

“…Some adopt the more aggressive prophylactic approach, which include prolonged systemic antibiotics. A recent meta-analysis demonstrated the efficacy of combined extended (>24 h) intravenous antibiotic administration and antibiotic-coated catheters [118]. When used in isolation, they outperformed perioperative administration of prophylactic antibiotics [118].…”

“…A recent meta-analysis demonstrated the efficacy of combined extended (>24 h) intravenous antibiotic administration and antibiotic-coated catheters [118]. When used in isolation, they outperformed perioperative administration of prophylactic antibiotics [118]. However, there are limitations when comparing studies in the existing literature.…”