Infections of central nervous system shunts and other devices
- Larry M Baddour, MD, FIDSA
Larry M Baddour, MD, FIDSA
- Professor of Medicine
- Mayo Clinic College of Medicine
- Patricia M Flynn, MD
Patricia M Flynn, MD
- Member, Department of Infectious Diseases
- St. Jude Children's Research Hospital
- Professor of Pediatrics
- University of Tennessee, Memphis
- Thomas Fekete, MD
Thomas Fekete, MD
- Professor of Medicine and Microbiology
- Temple University School of Medicine
- Section Editors
- Stephen B Calderwood, MD
Stephen B Calderwood, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
Cerebrospinal fluid (CSF) shunts are used in the setting of hydrocephalus to divert CSF to another part of the body for absorption . The approach to management of shunt infections is discussed here. Indications for shunt placement and other issues related to hydrocephalus are discussed separately. (See "Hydrocephalus in children: Management and prognosis" and "Normal pressure hydrocephalus".)
The proximal portion of the shunt catheter is most commonly placed in one of the cerebral ventricles but may also be placed in an intracranial cyst or the lumbar subarachnoid space. The distal portion of the shunt can be internalized or externalized. Internalized shunts most commonly drain into the peritoneum (ventriculoperitoneal, or VP, shunt), although, less commonly, they drain into the vascular space (ventriculoatrial, or VA, shunt).
Externalized devices (ventriculostomy catheters, also called external ventricular drains, or EVDs) are temporary devices typically placed in the setting of acute hydrocephalus for intracranial pressure monitoring and therapeutic diversion of cerebrospinal fluid. They may also be placed for interim management of hydrocephalus during antibiotic therapy for an infected internalized device that has been removed.
Other externalized central nervous system (CNS) devices such as Ommaya reservoirs (for administration of antimicrobial drugs or cancer chemotherapy) can also become infected. The proximal portion of these devices is typically placed in the intraventricular space but may also be placed in an abscess cavity or tumor. The distal portion of the device is a reservoir placed under the scalp (less commonly in the lumbar space) and accessed via a needle when needed.
INCIDENCE AND RISK FACTORS
The rate of internalized device infection ranges from 5 to 15 percent [2-12]. The highest infection rates have been observed during the initial month after placement, in patients requiring serial revisions, and in patients undergoing revision after treatment for an infected shunt [3,11].
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- SHUNT DEVICES
- INCIDENCE AND RISK FACTORS
- MICROBIOLOGY AND PATHOGENESIS
- CLINICAL MANIFESTATIONS
- Cerebrospinal fluid
- - Surveillance
- Blood cultures
- Device removal
- Antibiotic therapy
- - Systemic antibiotics
- - Intraventricular antibiotics
- - Antibiotic duration
- Antibiotic prophylaxis
- Antibiotic-impregnated catheters
- Prophylactic catheter exchange
- SUMMARY AND RECOMMENDATIONS