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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 90-92
Successful retention of the infected but functioning shunt system: Report of two cases and literature review
Hai-Long Li, Raynald Liu, Xiang-Li Cui, Song Lin
Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China
|Date of Submission||21-Oct-2012|
|Date of Decision||21-Oct-2012|
|Date of Acceptance||20-Jan-2013|
|Date of Web Publication||4-Mar-2013|
Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing
Source of Support: None, Conflict of Interest: None
|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 2020 Feb 28];61:90-2. Available from: http://www.neurologyindia.com/text.asp?2013/61/1/90/108034
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.  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.
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.  However, conservative management for patients with shunt infections has been attempted in earlier studies. ,, Compared with the route of antibiotics intraventricular administration through external drainage, the route via internal reservoir adopted by Brown et al.  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,  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.
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