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: Physiology, pathogenesis, and etiology" 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].
- Tunkel AR, Kaufman BA. Cerebrospinal Fluid Shunt Infections. In: Principles and Practice of Infectious Diseases, 6, Mandell GL, Bennett JE, Dolin R (Eds), Elsevier Inc, Philadelphia 2005. p.1126.
- Rotim K, Miklic P, Paladino J, et al. Reducing the incidence of infection in pediatric cerebrospinal fluid shunt operations. Childs Nerv Syst 1997; 13:584.
- Borgbjerg BM, Gjerris F, Albeck MJ, Børgesen SE. Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir (Wien) 1995; 136:1.
- Davis SE, Levy ML, McComb JG, Masri-Lavine L. Does age or other factors influence the incidence of ventriculoperitoneal shunt infections? Pediatr Neurosurg 1999; 30:253.
- Lam CH, Villemure JG. Comparison between ventriculoatrial and ventriculoperitoneal shunting in the adult population. Br J Neurosurg 1997; 11:43.
- Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 2001; 94:195.
- Mayhall CG, Archer NH, Lamb VA, et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 1984; 310:553.
- McGirt MJ, Zaas A, Fuchs HE, et al. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 2003; 36:858.
- Lishner M, Perrin RG, Feld R, et al. Complications associated with Ommaya reservoirs in patients with cancer. The Princess Margaret Hospital experience and a review of the literature. Arch Intern Med 1990; 150:173.
- Chamberlain MC, Kormanik PA, Barba D. Complications associated with intraventricular chemotherapy in patients with leptomeningeal metastases. J Neurosurg 1997; 87:694.
- George R, Leibrock L, Epstein M. Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg 1979; 51:804.
- Simon TD, Hall M, Riva-Cambrin J, et al. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr 2009; 4:156.
- Lyke KE, Obasanjo OO, Williams MA, et al. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis 2001; 33:2028.
- Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2002; 51:170.
- Dallacasa P, Dappozzo A, Galassi E, et al. Cerebrospinal fluid shunt infections in infants. Childs Nerv Syst 1995; 11:643.
- Aucoin PJ, Kotilainen HR, Gantz NM, et al. Intracranial pressure monitors. Epidemiologic study of risk factors and infections. Am J Med 1986; 80:369.
- Schoenbaum SC, Gardner P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J Infect Dis 1975; 131:543.
- Nelson JD. Cerebrospinal fluid shunt infections. Pediatr Infect Dis 1984; 3:S30.
- Younger JJ, Christensen GD, Bartley DL, et al. Coagulase-negative staphylococci isolated from cerebrospinal fluid shunts: importance of slime production, species identification, and shunt removal to clinical outcome. J Infect Dis 1987; 156:548.
- Diaz-Mitoma F, Harding GK, Hoban DJ, et al. Clinical significance of a test for slime production in ventriculoperitoneal shunt infections caused by coagulase-negative staphylococci. J Infect Dis 1987; 156:555.
- Filka J, Huttova M, Tuharsky J, et al. Nosocomial meningitis in children after ventriculoperitoneal shunt insertion. Acta Paediatr 1999; 88:576.
- Segal-Maurer S, Mariano N, Qavi A, et al. Successful treatment of ceftazidime-resistant Klebsiella pneumoniae ventriculitis with intravenous meropenem and intraventricular polymyxin B: case report and review. Clin Infect Dis 1999; 28:1134.
- Tush GM, Huneycutt S, Phillips A, Ward JD. Intraventricular quinupristin/dalfopristin for the treatment of vancomycin-resistant Enterococcus faecium shunt infection. Clin Infect Dis 1998; 26:1460.
- Vinchon M, Lemaitre MP, Vallée L, Dhellemmes P. Late shunt infection: incidence, pathogenesis, and therapeutic implications. Neuropediatrics 2002; 33:169.
- Baird C, O'Connor D, Pittman T. Late shunt infections. Pediatr Neurosurg 1999; 31:269.
- Greene KA, Clark RJ, Zabramski JM. Ventricular CSF shunt infections associated with Corynebacterium jeikeium: report of three cases and review. Clin Infect Dis 1993; 16:139.
- Knudsen JD, Nielsen CJ, Espersen F. Treatment of shunt-related cerebral ventriculitis due to Corynebacterium jeikeium with vancomycin administered intraventricularly. Case report. APMIS 1994; 102:317.
- Papadakis KA, Vartivarian SE, Vassilaki ME, Anaissie EJ. Stenotrophomonas maltophilia meningitis. Report of two cases and review of the literature. J Neurosurg 1997; 87:106.
- Bremer AA, Darouiche RO. Ventriculoperitoneal shunt infection due to Serratia marcescens. J Infect 2005; 50:138.
- Christenson JC, Pavia AT, Seskin K, et al. Meningitis due to Ochrobactrum anthropi: an emerging nosocomial pathogen. A report of 3 cases. Pediatr Neurosurg 1997; 27:218.
- Berner R, Heinen F, Pelz K, et al. Ventricular shunt infection and meningitis due to Bacillus cereus. Neuropediatrics 1997; 28:333.
- Midani S, Rathore MH. Mycobacterium fortuitum infection of ventriculoperitoneal shunt. South Med J 1999; 92:705.
- Chiou CC, Wong TT, Lin HH, et al. Fungal infection of ventriculoperitoneal shunts in children. Clin Infect Dis 1994; 19:1049.
- Conen A, Walti LN, Merlo A, et al. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis 2008; 47:73.
- Forward KR, Fewer HD, Stiver HG. Cerebrospinal fluid shunt infections. A review of 35 infections in 32 patients. J Neurosurg 1983; 59:389.
- Arze RS, Rashid H, Morley R, et al. Shunt nephritis: report of two cases and review of the literature. Clin Nephrol 1983; 19:48.
- Noetzel MJ, Baker RP. Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg 1984; 61:328.
- Meredith FT, Phillips HK, Reller LB. Clinical utility of broth cultures of cerebrospinal fluid from patients at risk for shunt infections. J Clin Microbiol 1997; 35:3109.
- McClinton D, Carraccio C, Englander R. Predictors of ventriculoperitoneal shunt pathology. Pediatr Infect Dis J 2001; 20:593.
- Lan CC, Wong TT, Chen SJ, et al. Early diagnosis of ventriculoperitoneal shunt infections and malfunctions in children with hydrocephalus. J Microbiol Immunol Infect 2003; 36:47.
- Hader WJ, Steinbok P. The value of routine cultures of the cerebrospinal fluid in patients with external ventricular drains. Neurosurgery 2000; 46:1149.
- Schade RP, Schinkel J, Roelandse FW, et al. Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. J Neurosurg 2006; 104:101.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- Whitehead WE, Kestle JR. The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons. Pediatr Neurosurg 2001; 35:205.
- James HE, Walsh JW, Wilson HD, et al. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 1980; 7:459.
- James HE, Walsh JW, Wilson HD, Connor JD. The management of cerebrospinal fluid shunt infections: a clinical experience. Acta Neurochir (Wien) 1981; 59:157.
- Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J 2002; 21:632.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Gombert ME, Landesman SH, Corrado ML, et al. Vancomycin and rifampin therapy for Staphylococcus epidermidis meningitis associated with CSF shunts: report of three cases. J Neurosurg 1981; 55:633.
- Jorgenson L, Reiter PD, Freeman JE, et al. Vancomycin disposition and penetration into ventricular fluid of the central nervous system following intravenous therapy in patients with cerebrospinal devices. Pediatr Neurosurg 2007; 43:449.
- Wang Q, Shi Z, Wang J, et al. Postoperatively administered vancomycin reaches therapeutic concentration in the cerebral spinal fluid of neurosurgical patients. Surg Neurol 2008; 69:126.
- Pfausler B, Spiss H, Beer R, et al. Treatment of staphylococcal ventriculitis associated with external cerebrospinal fluid drains: a prospective randomized trial of intravenous compared with intraventricular vancomycin therapy. J Neurosurg 2003; 98:1040.
- Myrianthefs P, Markantonis SL, Vlachos K, et al. Serum and cerebrospinal fluid concentrations of linezolid in neurosurgical patients. Antimicrob Agents Chemother 2006; 50:3971.
- Beer R, Engelhardt KW, Pfausler B, et al. Pharmacokinetics of intravenous linezolid in cerebrospinal fluid and plasma in neurointensive care patients with staphylococcal ventriculitis associated with external ventricular drains. Antimicrob Agents Chemother 2007; 51:379.
- Nagashima G, Okamoto N, Okuda M, et al. Effect of linezolid against postneurosurgical meningitis caused by methicillin-resistant Staphylococcus epidermidis: case report. J Infect Chemother 2008; 14:147.
- Levitz RE, Quintiliani R. Trimethoprim-sulfamethoxazole for bacterial meningitis. Ann Intern Med 1984; 100:881.
- Dudley MN, Levitz RE, Quintiliani R, et al. Pharmacokinetics of trimethoprim and sulfamethoxazole in serum and cerebrospinal fluid of adult patients with normal meninges. Antimicrob Agents Chemother 1984; 26:811.
- Gerber P, Stucki A, Acosta F, et al. Daptomycin is more efficacious than vancomycin against a methicillin-susceptible Staphylococcus aureus in experimental meningitis. J Antimicrob Chemother 2006; 57:720.
- Cottagnoud P, Pfister M, Acosta F, et al. Daptomycin is highly efficacious against penicillin-resistant and penicillin- and quinolone-resistant pneumococci in experimental meningitis. Antimicrob Agents Chemother 2004; 48:3928.
- Villani P, Regazzi MB, Marubbi F, et al. Cerebrospinal fluid linezolid concentrations in postneurosurgical central nervous system infections. Antimicrob Agents Chemother 2002; 46:936.
- Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007; 41:296.
- Gallagher RM, Pizer B, Ellison JA, Riordan FA. Glycopeptide insensitive Staphylococcus aureus subdural empyema treated with linezolid and rifampicin. J Infect 2008; 57:410.
- Kessler AT, Kourtis AP. Treatment of meningitis caused by methicillin-resistant Staphylococcus aureus with linezolid. Infection 2007; 35:271.
- Naesens R, Ronsyn M, Druwé P, et al. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol 2009; 58:1247.
- Vartzelis G, Theodoridou M, Daikos GL, et al. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005; 33:36.
- Lee DH, Palermo B, Chowdhury M. Successful treatment of methicillin-resistant staphylococcus aureus meningitis with daptomycin. Clin Infect Dis 2008; 47:588.
- Wallace MR, Sander AW, Licitra C, et al. Methicillin-resistant Staphylococcus aureus meningitis successfully treated with daptomycin. Infect Dis Clin Pract 2009; 17:69.
- Aguilar J, Urday-Cornejo V, Donabedian S, et al. Staphylococcus aureus meningitis: case series and literature review. Medicine (Baltimore) 2010; 89:117.
- Wen DY, Bottini AG, Hall WA, Haines SJ. Infections in neurologic surgery. The intraventricular use of antibiotics. Neurosurg Clin N Am 1992; 3:343.
- Lishner M, Scheinbaum R, Messner HA. Intrathecal vancomycin in the treatment of Ommaya reservoir infection by Staphylococcus epidermidis. Scand J Infect Dis 1991; 23:101.
- Sutherland GE, Palitang EG, Marr JJ, Luedke SL. Sterilization of Ommaya reservoir by instillation of vancomycin. Am J Med 1981; 71:1068.
- Swayne R, Rampling A, Newsom SW. Intraventricular vancomycin for treatment of shunt-associated ventriculitis. J Antimicrob Chemother 1987; 19:249.
- Nguyen MH, Harris SP, Muder RR, Pasculle AW. Antibiotic-resistant Acinetobacter meningitis in neurosurgical patients. Neurosurgery 1994; 35:851.
- Gump WC, Walsh JW. Intrathecal colistin for treatment of highly resistant Pseudomonas ventriculitis. Case report and review of the literature. J Neurosurg 2005; 102:915.
- Quinn AL, Parada JP, Belmares J, O'Keefe JP. Intrathecal colistin and sterilization of resistant Pseudomonas aeruginosa shunt infection. Ann Pharmacother 2005; 39:949.
- Cruciani M, Navarra A, Di Perri G, et al. Evaluation of intraventricular teicoplanin for the treatment of neurosurgical shunt infections. Clin Infect Dis 1992; 15:285.
- Ng J, Gosbell IB, Kelly JA, et al. Cure of multiresistant Acinetobacter baumannii central nervous system infections with intraventricular or intrathecal colistin: case series and literature review. J Antimicrob Chemother 2006; 58:1078.
- Karaiskos I, Galani L, Baziaka F, Giamarellou H. Intraventricular and intrathecal colistin as the last therapeutic resort for the treatment of multidrug-resistant and extensively drug-resistant Acinetobacter baumannii ventriculitis and meningitis: a literature review. Int J Antimicrob Agents 2013; 41:499.
- Manzella JP, Paul RL, Butler IL. CNS toxicity associated with intraventricular injection of cefazolin. Report of three cases. J Neurosurg 1988; 68:970.
- Wald SL, McLaurin RL. Cerebrospinal fluid antibiotic levels during treatment of shunt infections. J Neurosurg 1980; 52:41.
- James HE, Wilson HD, Connor JD, Walsh JW. Intraventricular cerebrospinal fluid antibiotic concentrations in patients with intraventricular infections. Neurosurgery 1982; 10:50.
- Choksey MS, Malik IA. Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 2004; 75:87.
- Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
- Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 2006; :CD005365.
- Prabhu VC, Kaufman HH, Voelker JL, et al. Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence. Surg Neurol 1999; 52:226.
- Morris A, Low DE. Nosocomial bacterial meningitis, including central nervous system shunt infections. Infect Dis Clin North Am 1999; 13:735.
- Ragel BT, Browd SR, Schmidt RH. Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 2006; 105:242.
- Klimo P Jr, Van Poppel M, Thompson CJ, et al. 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. J Neurosurg Pediatr 2014; 14 Suppl 1:44.
- Aryan HE, Meltzer HS, Park MS, et al. Initial experience with antibiotic-impregnated silicone catheters for shunting of cerebrospinal fluid in children. Childs Nerv Syst 2005; 21:56.
- Govender ST, Nathoo N, van Dellen JR. Evaluation of an antibiotic-impregnated shunt system for the treatment of hydrocephalus. J Neurosurg 2003; 99:831.
- Zabramski JM, Whiting D, Darouiche RO, et al. Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial. J Neurosurg 2003; 98:725.
- Kaufmann AM, Lye T, Redekop G, et al. Infection rates in standard vs. hydrogel coated ventricular catheters. Can J Neurol Sci 2004; 31:506.
- Klimo P Jr, Thompson CJ, Ragel BT, Boop FA. Antibiotic-impregnated shunt systems versus standard shunt systems: a meta- and cost-savings analysis. J Neurosurg Pediatr 2011; 8:600.
- Klimo P Jr, Thompson CJ, Baird LC, et al. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 7: Antibiotic-impregnated shunt systems versus conventional shunts in children: a systematic review and meta-analysis. J Neurosurg Pediatr 2014; 14 Suppl 1:53.
- Wong GK, Poon WS, Wai S, et al. Failure of regular external ventricular drain exchange to reduce cerebrospinal fluid infection: result of a randomised controlled trial. J Neurol Neurosurg Psychiatry 2002; 73:759.
- Holloway KL, Barnes T, Choi S, et al. Ventriculostomy infections: the effect of monitoring duration and catheter exchange in 584 patients. J Neurosurg 1996; 85:419.
- 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