1. SHUNT INFECTION

2. Introduction Ventricular catheter placement one of the most common neurosurgical procedures Ventricular catheter placement one of the most common neurosurgical procedures One of the most common complications associated is infection One of the most common complications associated is infection Infection: positive CSF culture/ or from shunt hardware Infection: positive CSF culture/ or from shunt hardware More common in pediatric population More common in pediatric population

3. CRITERIA –Brown and Durand et al., CRITERIA –Brown and Durand et al., Positive CSF/ shunt tip culture in patient with clinical presentation of ABM/ shunt malfunction Positive CSF/ shunt tip culture in patient with clinical presentation of ABM/ shunt malfunction At least 1 parameter of CSF inflammation At least 1 parameter of CSF inflammation TLC->0.25x10^9 with leucocytosis TLC->0.25x10^9 with leucocytosis CSF lactate conc. >0.35mmol/l CSF lactate conc. >0.35mmol/l CSF glucose/serum glucose <0.4 CSF glucose/serum glucose <0.4 CSF glucose value <2.5mmol CSF glucose value <2.5mmol

4. Implications High mortality/ morbidity High mortality/ morbidity Extended hospital stay Extended hospital stay Loss or delay of educational/ developmental milestones Loss or delay of educational/ developmental milestones Reduced health related quality of life style Reduced health related quality of life style Large cost Large cost

5. Infection Rate Varied rate at different centers Varied rate at different centers Walter et al., 18%/ patient: 20 year study Walter et al., 18%/ patient: 20 year study 5% / surgical procedure 5% / surgical procedure Ammirati et al., 22%/ patient and 6%/ procedure Ammirati et al., 22%/ patient and 6%/ procedure Borgberj et al., 7.4% Borgberj et al., 7.4% ISPN multi centric study: 6.5% ISPN multi centric study: 6.5%

6. Time to Infection 92% of infections occurred within 3 months -Casey and colleagues 92% of infections occurred within 3 months -Casey and colleagues This finding generally confirmed by most This finding generally confirmed by most

7. Risk factors Age: <6 months-19% versus 7% in older population –Casey and colleagues Age: <6 months-19% versus 7% in older population –Casey and colleagues Time period Time period Educational level/ surgical skill of surgeons Educational level/ surgical skill of surgeons Length and time of surgery Length and time of surgery Use of antibiotic before and after surgery Use of antibiotic before and after surgery Method for placement of distal catheter Method for placement of distal catheter

8. Type of shunt Type of shunt Reason for shunt Reason for shunt Shunt revision Shunt revision Concurrent infection Concurrent infection Presence of spinal dysraphism - Daniel M Scuba etal., Presence of spinal dysraphism - Daniel M Scuba etal.,

9. Route of infection Blood stream Blood stream Shunt tubing Shunt tubing Contamination with epidermal commensals during surgery Contamination with epidermal commensals during surgery

10. Pathogenesis Risk factors Risk factors Neutrophil and monocyte adhere poorly to shunt system Neutrophil and monocyte adhere poorly to shunt system Weak phagocytosis Weak phagocytosis Shunt surface irregularities harbor organism Shunt surface irregularities harbor organism Inoculums size/ virulence of organism/ host defense Inoculums size/ virulence of organism/ host defense

11. Organisms Early/ late Early/ late Staphylococcus epidermidis : coagulase negative Staphylococcus epidermidis : coagulase negative Staphylococcus aureus Staphylococcus aureus Escherichia coli Escherichia coli

12. Proteus mirabilis Proteus mirabilis Klebsiella pneumonia Klebsiella pneumonia Propionibacterium Propionibacterium Fungal Fungal

13. Presentation Variable and age dependant Variable and age dependant Headache Headache Lethargy Lethargy Nausea/ vomiting Nausea/ vomiting Irritability Irritability Apnea Apnea

14. Bradycardia Bradycardia Fever Fever Gait disturbances Gait disturbances Seizures Seizures Visual disturbances Visual disturbances Gaze palsy Gaze palsy

15. Papilloedema Papilloedema Abdominal pain Abdominal pain Erythema/ edema along shunt tube Erythema/ edema along shunt tube Fluid collection and pseudo cyst Fluid collection and pseudo cyst Features of shunt nephritis Features of shunt nephritis Sub acute bacterial endocarditis Sub acute bacterial endocarditis

16. Evaluation and Diagnosis Detailed history Detailed history Physical examination Physical examination Routine blood tests: Hb/ TLC/ DLC/ urine analysis/ blood cultures Routine blood tests: Hb/ TLC/ DLC/ urine analysis/ blood cultures X-Ray X-Ray USG USG CT scan: ventriculitis/ malfunction CT scan: ventriculitis/ malfunction Shunt tap with CSF analysis and culture Shunt tap with CSF analysis and culture

17. Treatment Surgical removal of the infected shunt Surgical removal of the infected shunt Antibiotic usage: empirical/ culture based Antibiotic usage: empirical/ culture based Re-insertion: 10- 14 days later with at least 48 hours Re-insertion: 10- 14 days later with at least 48 hours Shunt exteriorization Shunt exteriorization Repeated lumbar drainage Repeated lumbar drainage

18. Shunt replacement: new/ contra lateral site Shunt replacement: new/ contra lateral site Procedures for pseudo-cyst/ abscess Procedures for pseudo-cyst/ abscess Antibiotics alone: less effective Brian T et al., Antibiotics alone: less effective Brian T et al., Role of intrathecal/ ventricular antibiotics Brian et al., Role of intrathecal/ ventricular antibiotics Brian et al.,

19. Prevention Sterile surgical technique Sterile surgical technique Perioperative antibiotic use Perioperative antibiotic use Role of first dose antibiotic Role of first dose antibiotic Post operative antibiotic coverage Post operative antibiotic coverage Use of shunt tubing with polymeric silicon Use of shunt tubing with polymeric silicon

20. Impregnation of antibiotic Impregnation of antibiotic Use of one piece system colak, albright etal., Use of one piece system colak, albright etal., Hypothermia during surgery –gerszten pc etal., Hypothermia during surgery –gerszten pc etal., Annual or biannual screening Annual or biannual screening

21. Pharmacology of IVT drugs Prevent seeding of CSF by bacteria Prevent seeding of CSF by bacteria Staph species most common Staph species most common Drugs don’t cross BBB Drugs don’t cross BBB IVT provides higher CSF conc. of drugs IVT provides higher CSF conc. of drugs Thus better surgical prophylaxis Thus better surgical prophylaxis Current concept: antibiotic must be there when bacteria arrive Current concept: antibiotic must be there when bacteria arrive

22. Surgical technique- Do’s First case in morning First case in morning Minimal staff Minimal staff Send scrubbing technician out kestle et al., Send scrubbing technician out kestle et al., Double gloving kulkarni, noel etal., Double gloving kulkarni, noel etal., Antibiotic prophylaxis chokesey etal., Antibiotic prophylaxis chokesey etal., Pouring of bactericidal substance doubly Pouring of bactericidal substance doubly Skin draping Skin draping

23. Opening of shunt just before insertion Opening of shunt just before insertion Change gloves while shunt handling Change gloves while shunt handling Minimal manipulation with connector Minimal manipulation with connector Shunt patency checked with antibiotic saline Shunt patency checked with antibiotic saline Usage of AIS Usage of AIS Single piece shunt Single piece shunt

24. Surgical technique- Dont’s Cut/ slit/ make holes in lower shunt end Cut/ slit/ make holes in lower shunt end Tunnel superficially Tunnel superficially Handle skin Handle skin Stitch infection as shunt infection Stitch infection as shunt infection H2 blockers H2 blockers Perform in presence of foci of infection Perform in presence of foci of infection

25. Thank you