Correspondence Address:
Suresh Sankhla
Department of Neurosurgery, Dr. B. Nanavati Hospital, Vile Parle, Mumbai
India

Full Text

Shunt infection remains a major problem in the treatment of children with hydrocephalus. Recent advances in technology and techniques have not made any significant difference in the prevention of CSF infection which still occurs in approximately 10% of the patients. The treatment of infection is standard and generally includes the removal or externalization of the shunt as well as antibiotic therapy, followed by the reinsertion of a new shunt, usually at a different site. Some surgeons prefer the placement of an external ventricular drain (EVD) along with antibiotic treatment. Unfortunately, despite successful treatment, reinfection of shunts is very common. Recent studies have disclosed an alarmingly high incidence of recurrent shunt infections. [1],[2] In a multicenter pilot study published a few years back, the shunt reinfection rate was reported to be 26%. [2] Two-thirds of these recurrent infections are caused by the same organism. The high recurrence rate after treatment of a shunt infection is difficult to accept and calls for an immediate need to evaluate current treatment strategies. We also need to focus our efforts on changing old and ineffective techniques, exploring innovative methods, and adopting more efficient existing or new technologies.

As we all know, shunt infection is observed more commonly in children than in adults. Also well-known is the fact that children with hydrocephalus secondary to intraventricular hemorrhage of prematurity or myelomeningocele, are more vulnerable to develop this complication. Who should be treating these children? It would not be unreasonable to recommend that, if not all, at least the children at "higher risk" should be treated at major pediatric centers where neurosurgical patients are routinely treated by pediatric neurosurgeons.

The optimal duration of antibiotic therapy for infected shunts is not known. There is also no proven association between treatment time and the recurrence of shunt infection. Sources such as anecdotal reports, uncontrolled trials, and unpublished data from colleagues are inconsistent and make the matter more confusing. Clearly, more multicentric, randomized, controlled studies and trials are required to address this important issue. Inadequately treated children are definitely at a greater risk of developing recurrent and resistant shunt infections. On the other hand, patients who receive antibiotics for longer durations, require prolonged hospital stay and are thus, at an increased risk of acquiring potentially serious nosocomial infections. The treatment cost in these patients who require EVDs and intravenous antibiotics in intensive care units for longer periods can be considerably high and perhaps, unsustainable in the present health care environment. Potential strategies to decrease treatment time and, therefore, to decrease hospital stay, should be explored and investigated further.

Now that antibiotic-impregnated ventricular drains and shunt catheters are available, their role in the prevention and treatment of shunt infection needs to be evaluated. In a prospective study from Australia in 2007, the authors were able to reduce shunt infection rates from 6.5 to 1.2% by using antibiotic-impregnated shunt catheters. [3] It is possible that the use of such a shunt or EVD system during the treatment of an infection might more rapidly or more effectively clear the CSF infection. However, more prospective studies such as this one will throw more light on the effectiveness of this apparently useful catheter system. Similarly, more research would be necessary to evaluate the role of antibiotic-impregnated shunt catheters at the time of shunt reinsertion after the treatment of an infection.

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