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Infections of cerebrospinal fluid shunts and other devices

Larry M Baddour, MD, FIDSA, FAHA
Patricia M Flynn, MD
Thomas Fekete, MD
Section Editors
Stephen B Calderwood, MD
Morven S Edwards, MD
Deputy Editor
Anna R Thorner, MD


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 management of bacterial meningitis in neonates, children, and adults is discussed in detail separately. (See "Bacterial meningitis in the neonate: Treatment and outcome" and "Bacterial meningitis in children older than one month: Treatment and prognosis" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults".)


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 [VP] shunt), although, less commonly, they drain into the vascular space (ventriculoatrial [VA] shunt) or the pleural space (ventriculopleural shunt).

Externalized devices (ventriculostomy catheters, also called external ventricular drains [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.

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Literature review current through: Nov 2017. | This topic last updated: Aug 15, 2017.
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  1. Mayhall CG, Archer NH, Lamb VA, et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 1984; 310:553.
  2. 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.
  3. 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.
  4. Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017.
  5. Renier D, Lacombe J, Pierre-Kahn A, et al. Factors causing acute shunt infection. Computer analysis of 1174 operations. J Neurosurg 1984; 61:1072.
  6. Younger JJ, Simmons JC, Barrett FF. Operative related infection rates for ventriculoperitoneal shunt procedures in a children's hospital. Infect Control 1987; 8:67.
  7. Quigley MR, Reigel DH, Kortyna R. Cerebrospinal fluid shunt infections. Report of 41 cases and a critical review of the literature. Pediatr Neurosci 1989; 15:111.
  8. Kontny U, Höfling B, Gutjahr P, et al. CSF shunt infections in children. Infection 1993; 21:89.
  9. Piatt JH Jr, Carlson CV. A search for determinants of cerebrospinal fluid shunt survival: retrospective analysis of a 14-year institutional experience. Pediatr Neurosurg 1993; 19:233.
  10. McGirt MJ, Leveque JC, Wellons JC 3rd, et al. Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg 2002; 36:248.
  11. Vinchon M, Dhellemmes P. Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst 2006; 22:692.
  12. van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med 2010; 362:146.
  13. Simon TD, Butler J, Whitlock KB, et al. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 2014; 164:1462.
  14. Ramanan M, Lipman J, Shorr A, Shankar A. A meta-analysis of ventriculostomy-associated cerebrospinal fluid infections. BMC Infect Dis 2015; 15:3.
  15. Lyke KE, Obasanjo OO, Williams MA, et al. Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients. Clin Infect Dis 2001; 33:2028.
  16. Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES Jr. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery 2002; 51:170.
  17. Dallacasa P, Dappozzo A, Galassi E, et al. Cerebrospinal fluid shunt infections in infants. Childs Nerv Syst 1995; 11:643.
  18. Aucoin PJ, Kotilainen HR, Gantz NM, et al. Intracranial pressure monitors. Epidemiologic study of risk factors and infections. Am J Med 1986; 80:369.
  19. 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.
  20. George R, Leibrock L, Epstein M. Long-term analysis of cerebrospinal fluid shunt infections. A 25-year experience. J Neurosurg 1979; 51:804.
  21. Schoenbaum SC, Gardner P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J Infect Dis 1975; 131:543.
  22. Nelson JD. Cerebrospinal fluid shunt infections. Pediatr Infect Dis 1984; 3:S30.
  23. 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.
  24. 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.
  25. Filka J, Huttova M, Tuharsky J, et al. Nosocomial meningitis in children after ventriculoperitoneal shunt insertion. Acta Paediatr 1999; 88:576.
  26. 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.
  27. 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.
  28. Vinchon M, Lemaitre MP, Vallée L, Dhellemmes P. Late shunt infection: incidence, pathogenesis, and therapeutic implications. Neuropediatrics 2002; 33:169.
  29. Baird C, O'Connor D, Pittman T. Late shunt infections. Pediatr Neurosurg 1999; 31:269.
  30. 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.
  31. 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.
  32. 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.
  33. Bremer AA, Darouiche RO. Ventriculoperitoneal shunt infection due to Serratia marcescens. J Infect 2005; 50:138.
  34. 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.
  35. Berner R, Heinen F, Pelz K, et al. Ventricular shunt infection and meningitis due to Bacillus cereus. Neuropediatrics 1997; 28:333.
  36. Midani S, Rathore MH. Mycobacterium fortuitum infection of ventriculoperitoneal shunt. South Med J 1999; 92:705.
  37. Chiou CC, Wong TT, Lin HH, et al. Fungal infection of ventriculoperitoneal shunts in children. Clin Infect Dis 1994; 19:1049.
  38. Braxton EE Jr, Ehrlich GD, Hall-Stoodley L, et al. Role of biofilms in neurosurgical device-related infections. Neurosurg Rev 2005; 28:249.
  39. Snowden JN, Beaver M, Smeltzer MS, Kielian T. Biofilm-infected intracerebroventricular shunts elicit inflammation within the central nervous system. Infect Immun 2012; 80:3206.
  40. Forward KR, Fewer HD, Stiver HG. Cerebrospinal fluid shunt infections. A review of 35 infections in 32 patients. J Neurosurg 1983; 59:389.
  41. Arze RS, Rashid H, Morley R, et al. Shunt nephritis: report of two cases and review of the literature. Clin Nephrol 1983; 19:48.
  42. Centers for Disease Control and Prevention. CDC/NHSN surveillance definitions for specific types of infections. https://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf (Accessed on April 10, 2017).
  43. Noetzel MJ, Baker RP. Shunt fluid examination: risks and benefits in the evaluation of shunt malfunction and infection. J Neurosurg 1984; 61:328.
  44. 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.
  45. McClinton D, Carraccio C, Englander R. Predictors of ventriculoperitoneal shunt pathology. Pediatr Infect Dis J 2001; 20:593.
  46. 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.
  47. Tung H, Raffel C, McComb JG. Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts. J Neurosurg 1991; 75:541.
  48. Fulkerson DH, Boaz JC. Cerebrospinal fluid eosinophilia in children with ventricular shunts. J Neurosurg Pediatr 2008; 1:288.
  49. Heidemann SM, Fiore M, Sood S, Ham S. Eosinophil activation in the cerebrospinal fluid of children with shunt obstruction. Pediatr Neurosurg 2010; 46:255.
  50. Li Y, Zhang G, Ma R, et al. The diagnostic value of cerebrospinal fluids procalcitonin and lactate for the differential diagnosis of post-neurosurgical bacterial meningitis and aseptic meningitis. Clin Biochem 2015; 48:50.
  51. 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.
  52. James HE, Walsh JW, Wilson HD, et al. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 1980; 7:459.
  53. James HE, Walsh JW, Wilson HD, Connor JD. The management of cerebrospinal fluid shunt infections: a clinical experience. Acta Neurochir (Wien) 1981; 59:157.
  54. Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J 2002; 21:632.
  55. 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.
  56. Pelegrín I, Lora-Tamayo J, Gómez-Junyent J, et al. Management of Ventriculoperitoneal Shunt Infections in Adults: Analysis of Risk Factors Associated With Treatment Failure. Clin Infect Dis 2017; 64:989.
  57. 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.
  58. 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.
  59. 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.
  60. 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.
  61. Aguilar J, Urday-Cornejo V, Donabedian S, et al. Staphylococcus aureus meningitis: case series and literature review. Medicine (Baltimore) 2010; 89:117.
  62. Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007; 41:296.
  63. Myrianthefs P, Markantonis SL, Vlachos K, et al. Serum and cerebrospinal fluid concentrations of linezolid in neurosurgical patients. Antimicrob Agents Chemother 2006; 50:3971.
  64. 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.
  65. 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.
  66. Levitz RE, Quintiliani R. Trimethoprim-sulfamethoxazole for bacterial meningitis. Ann Intern Med 1984; 100:881.
  67. 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.
  68. 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.
  69. 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.
  70. Villani P, Regazzi MB, Marubbi F, et al. Cerebrospinal fluid linezolid concentrations in postneurosurgical central nervous system infections. Antimicrob Agents Chemother 2002; 46:936.
  71. Gallagher RM, Pizer B, Ellison JA, Riordan FA. Glycopeptide insensitive Staphylococcus aureus subdural empyema treated with linezolid and rifampicin. J Infect 2008; 57:410.
  72. Kessler AT, Kourtis AP. Treatment of meningitis caused by methicillin-resistant Staphylococcus aureus with linezolid. Infection 2007; 35:271.
  73. 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.
  74. Vartzelis G, Theodoridou M, Daikos GL, et al. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005; 33:36.
  75. Lee DH, Palermo B, Chowdhury M. Successful treatment of methicillin-resistant staphylococcus aureus meningitis with daptomycin. Clin Infect Dis 2008; 47:588.
  76. Wallace WR, Sander AW, Licitra C, et al. Methicillin-resistant Staphylococcus aureus meningitis successfully treated with daptomycin. Infect Dis Clin North Am 2009; 17:69.
  77. Wen DY, Bottini AG, Hall WA, Haines SJ. Infections in neurologic surgery. The intraventricular use of antibiotics. Neurosurg Clin N Am 1992; 3:343.
  78. Chamberlain MC, Kormanik PA, Barba D. Complications associated with intraventricular chemotherapy in patients with leptomeningeal metastases. J Neurosurg 1997; 87:694.
  79. 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.
  80. Sutherland GE, Palitang EG, Marr JJ, Luedke SL. Sterilization of Ommaya reservoir by instillation of vancomycin. Am J Med 1981; 71:1068.
  81. Swayne R, Rampling A, Newsom SW. Intraventricular vancomycin for treatment of shunt-associated ventriculitis. J Antimicrob Chemother 1987; 19:249.
  82. Nguyen MH, Harris SP, Muder RR, Pasculle AW. Antibiotic-resistant Acinetobacter meningitis in neurosurgical patients. Neurosurgery 1994; 35:851.
  83. 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.
  84. Quinn AL, Parada JP, Belmares J, O'Keefe JP. Intrathecal colistin and sterilization of resistant Pseudomonas aeruginosa shunt infection. Ann Pharmacother 2005; 39:949.
  85. 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.
  86. 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.
  87. 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.
  88. Manzella JP, Paul RL, Butler IL. CNS toxicity associated with intraventricular injection of cefazolin. Report of three cases. J Neurosurg 1988; 68:970.
  89. Wald SL, McLaurin RL. Cerebrospinal fluid antibiotic levels during treatment of shunt infections. J Neurosurg 1980; 52:41.
  90. James HE, Wilson HD, Connor JD, Walsh JW. Intraventricular cerebrospinal fluid antibiotic concentrations in patients with intraventricular infections. Neurosurgery 1982; 10:50.
  91. Rogers EA, Kimia A, Madsen JR, et al. Predictors of ventricular shunt infection among children presenting to a pediatric emergency department. Pediatr Emerg Care 2012; 28:405.
  92. 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.
  93. Pfisterer W, Mühlbauer M, Czech T, Reinprecht A. Early diagnosis of external ventricular drainage infection: results of a prospective study. J Neurol Neurosurg Psychiatry 2003; 74:929.
  94. Walti LN, Conen A, Coward J, et al. Characteristics of infections associated with external ventricular drains of cerebrospinal fluid. J Infect 2013; 66:424.
  95. Choksey MS, Malik IA. Zero tolerance to shunt infections: can it be achieved? J Neurol Neurosurg Psychiatry 2004; 75:87.
  96. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
  97. Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database Syst Rev 2006; :CD005365.
  98. 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.
  99. Morris A, Low DE. Nosocomial bacterial meningitis, including central nervous system shunt infections. Infect Dis Clin North Am 1999; 13:735.
  100. Ragel BT, Browd SR, Schmidt RH. Surgical shunt infection: significant reduction when using intraventricular and systemic antibiotic agents. J Neurosurg 2006; 105:242.
  101. 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.
  102. Stenager E, Gerner-Smidt P, Kock-Jensen C. Ventriculostomy-related infections--an epidemiological study. Acta Neurochir (Wien) 1986; 83:20.
  103. 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.
  104. 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.
  105. Thomas R, Lee S, Patole S, Rao S. Antibiotic-impregnated catheters for the prevention of CSF shunt infections: a systematic review and meta-analysis. Br J Neurosurg 2012; 26:175.
  106. Parker SL, Anderson WN, Lilienfeld S, et al. Cerebrospinal shunt infection in patients receiving antibiotic-impregnated versus standard shunts. J Neurosurg Pediatr 2011; 8:259.
  107. Sonabend AM, Korenfeld Y, Crisman C, et al. Prevention of ventriculostomy-related infections with prophylactic antibiotics and antibiotic-coated external ventricular drains: a systematic review. Neurosurgery 2011; 68:996.
  108. 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.
  109. 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.