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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 1  |  Page : 90-92

Successful retention of the infected but functioning shunt system: Report of two cases and literature review


Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China

Date of Submission21-Oct-2012
Date of Decision21-Oct-2012
Date of Acceptance20-Jan-2013
Date of Web Publication4-Mar-2013

Correspondence Address:
Song Lin
Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.108034

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How to cite this article:
Li HL, Liu R, Cui XL, Lin S. Successful retention of the infected but functioning shunt system: Report of two cases and literature review. Neurol India 2013;61:90-2

How to cite this URL:
Li HL, Liu R, Cui XL, Lin S. Successful retention of the infected but functioning shunt system: Report of two cases and literature review. Neurol India [serial online] 2013 [cited 2019 Sep 18];61:90-2. Available from: http://www.neurologyindia.com/text.asp?2013/61/1/90/108034


Sir,

Shunt infection is the most common complication associated with ventriculoperitoneal (VP) shunt. Current standard managements for shunt infections include shunt removal, external drainage of cerebrospinal fluid (CSF), and antibiotic therapy followed by replacement of a new shunt. [1] However, there is little experience on completely curing shunt infection without removal of the catheter.

Two men diagnosed with shunt infection were managed by conservative treatment including retention of the primary shunt system, placement of a new extraventricular drainage (EVD; Medtronic Inc., Minneapolis, USA), and intra-reservoir, intraventricular, and intravenous antibiotics administration [Table 1]. After a 2-week course, a good response was achieved. Within a minimum of 6-months follow-up, there was no clinical evidence of infection, reinfection, or shunt malfunction in both the patients.
Table 1: Clinical data of patients with shunt infections


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Vancomycin was given by intravenous, intra-reservoir, and intraventricular routes, according to the drug susceptibility testing. These two patients received vancomycin 1000 mg q12h IV for about 14 days. An approximate 2-week course of intra-reservoir and intraventricular vancomycin 20 mg daily was given through control reservoir of shunt system and a totally enclosed, external CSF drainage system, respectively. After every injection, the EVD system was closed and opened 2 hours later. Samples of CSF were collected for culture and regular laboratory examination every 2-3 days during the treatment period, after 1 week, and after 1 month of successful recovery.

Generally, the best option for treating patients with shunt infections is removal of the infected shunt and replacement of a new shunt when CSF sterility is achieved. [1] However, conservative management for patients with shunt infections has been attempted in earlier studies. [2],[3],[4] Compared with the route of antibiotics intraventricular administration through external drainage, the route via internal reservoir adopted by Brown et al. [2] has less chance of secondary infection. However, once the infection has not been completely eradicated or catheter blockage occured, removal of either the original shunt or the reservoir would be necessary. Considering this possibility, in both the patients, we still selected EVD as the route for intraventricular administration of antibiotics. We believe that this external drainage has two advantages compared with internal reservoir in conservative management for patients with shunt infection. First, the infected CSF containing bacterial colony can be drained outward from ventricle via this route. This can accelerate reduction of bacteria in CSF and thus contribute to alleviate systemic reactions such as fever and headache. Second, a markedly elevated protein caused by infection also can be drained. When the infection is successfully cured, the EVD could be removed immediately in order to discard redundant catheter in a patient's ventricle. Provided that the infection is not successfully eradicated and that the shunt blockage simultaneously take place, the external drainage may helpful to control intracranial pressure, increasing which could be life threatening. In our opinion, this is the biggest advantage compared with internal reservoir. Although Brown et al. reported that the blockage-free survival times were not significantly different (P =0.69, long rank test) between conservative management group and a large cohort of uninfected patients with VP shunts in his institution, [2] we still consider that the drainage of the elevated protein would be helpful to reduce the incidence of catheter blockage. In addition to bacterial colonization and subsequent biofilm formation on the surfaces of the shunts, shunt infections always result in intraluminal colonization. Intra-reservoir route in this study, which is feasible in product license of shunt system, is developed to eliminate the intraluminal colonization and to prevent distal infection.

This is the first report of a new modality of conservative treatment of maintaining the infected, but functioning shunt system and administrating antibiotics through an EVD. Our findings provide a new way to manage shunt system that is infected but functioning.

 
  References Top

1.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;35:205-10.  Back to cited text no. 1
[PUBMED]    
2.Brown EM, Edwards RJ, Pople IK. Conservative management of patients with cerebrospinal fluid shunt infections. Neurosurgery 2008;62:661-9.  Back to cited text no. 2
[PUBMED]    
3.Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: A decision analysis. Pediatr Infect Dis J 2002;21:632-6.  Back to cited text no. 3
[PUBMED]    
4.Yilmaz A, Dalgic N, Musluman M, Sancar M, Colak I, Aydin Y. Linezolid treatment of shunt-related cerebrospinal fluid infections in children. J Neurosurg Pediatr 2010;5:443-8.  Back to cited text no. 4
    



 
 
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