Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 2988  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (737 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed4598    
    Printed114    
    Emailed2    
    PDF Downloaded165    
    Comments [Add]    
    Cited by others 3    

Recommend this journal

 


 
Table of Contents    
ORIGINAL ARTICLE
Year : 2016  |  Volume : 64  |  Issue : 4  |  Page : 671-676

Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends


1 Department of Neurosurgery, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
2 Department of Microbiology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Dr. Daljit Singh
Room No. 529, Department of Neurosurgery, G. B. Pant Institute of Postgraduate Medical Education and Research, 1, JLN Marg, New Delhi - 110 002
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.185408

Rights and Permissions

 » Abstract 

Introduction: Infection associated with a ventriculoperitoneal shunt is a severe complication with a high morbidity and substantial mortality. There are no guidelines to choose antibiotics in case of shunt infection. Most surgeons use antibiotics of their choice whereas limited centres follow their own antibiotic policy. An alarming increase in antibiotic resistance has led to rising morbidity and mortality.
Materials and Methods: This was a retrospective analysis of patients who underwent ventriculoperitoneal shunt surgery between January 2010 and December 2015 at our institution. Shunt tubes and cerebrospinal fluid were sent for culture and sensitivity in patients who were suspected clinically of having shunt tube infections. The processing of the samples was done by standard techniques, and the identification of the organism along with its sensitivity pattern was performed using Vitek 2 system.
Results: A total of 1186 ventriculoperitoneal shunt surgeries were performed during this period at our institute in patients of all age groups. There were 757 (63.8%) male and 429 (36.2%) female patients. A total of 156 samples of patients were sent for culture and sensitivity during this period, out of which 79 (50.6%) samples had growth of an organism either in the cerebrospinal fluid [36 (23.1%)], shunt tubing [16 (10.2%)], or in both [27 (17.3%)]. The most common organisms grown in the cultures were Staphylococcus aureus [65 (82.3%)] or coagulase-negative Staphylococcus [22 (25.3%)] in the Gram-positive group and Escherichia coli [17 (21.5%)] in the Gram-negative group. Over the last 6 years, the sensitivity pattern of both Gram-negative and Gram-positive bacteria has shown alarming decreasing sensitivity for various commonly used antibiotics.
Conclusion: Ventriculoperitoneal shunt infection has become an important concern in cases of hydrocephalus. Due to the development of a high proportion of antibiotic resistance, we recommend an empirical therapy of antibiotic therapy for prophylaxis and suspected infection in ventriculoperitoneal shunt surgery.


Keywords: Antibiotic resistance; hydrocephalus; infection; ventriculoperitoneal shunt


How to cite this article:
Kumar V, Shah AS, Singh D, Loomba PS, Singh H, Jagetia A. Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends. Neurol India 2016;64:671-6

How to cite this URL:
Kumar V, Shah AS, Singh D, Loomba PS, Singh H, Jagetia A. Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends. Neurol India [serial online] 2016 [cited 2020 Sep 19];64:671-6. Available from: http://www.neurologyindia.com/text.asp?2016/64/4/671/185408



 » Introduction Top


Hydrocephalus is a very commonly encountered entity in neurosurgical practice in both pediatric and adult population. Despite the growing use of endoscopic third ventriculostomy, ventriculoperitoneal (VP) shunt has been the treatment of choice for hydrocephalus since the invention of the shunt valve by John Holter in 1959.[1] Cerebrospinal fluid (CSF) shunting procedures provide a rapid means of normalizing intracranial pressure and can prevent neuronal damage as well as other detrimental sequelae.[2],[3] Recently, adjustable pressure valves and antibiotic-impregnated shunt catheters have been used to continue the trend of catheter development to ensure better outcomes.[4],[5],[6],[7],[8],[9],[10]

Despite significant developments in the technology and design of VP shunt systems, shunt failure remains a significant problem in neurological surgery. Many studies have been performed to investigate the complication rates and causes of failure in both children and adults.[11],[12],[13],[14],[15],[16],[17],[18],[19] Some of these studies have suggested that there may be specific risk factors for shunt failure such as a younger age, male sex, socioeconomic status,[19] and ventricular catheter location.[14] In addition, several reports have calculated shunt survival rates at different time points after the initial shunt placement.[11],[14],[16],[19],[20]

Infection associated with a VP shunt is a severe complication with a high morbidity and substantial mortality,[21] with infection rates ranging from 2 to 27%, often with a poor outcome.[22],[23],[24],[25],[26],[27] Shunt-associated infections are most frequently (65%) caused by coagulase-negative Staphylococcus.[26],[28],[29] Gram-negative bacteria are the next most frequent pathogens, accounting for 19–22% of cases.[26],[30] Several independent risk factors for shunt infection have been identified, including previous shunt-associated infection, shunt revision for dysfunction, postoperative CSF leakage, an advanced age, duration of the shunt placement operation, experience of the neurosurgeon, and use of a neuroendoscope.[11],[31],[32]

In addition, the use of antibiotics in the treatment of shunt infection varies substantially. The indiscriminate use of antibiotics and the lack of proper guidelines for treatment have contributed to an increase in antibiotic resistance.

We present a retrospective review of patients who underwent VP shunt surgery for hydrocephalus with the aim to analyze the incidence of shunt revision and the patterns of shunt infection. We also analyzed the change in antibiotic sensitivity pattern in the past 6 years.


 » Materials and Methods Top


A 6-year (January 2010 to December 2015) retrospective analysis of patients who underwent VP shunt placement at our institute was performed. The demographic data of all cases were tabulated for etiology, age, and clinical presentation.

The case records of those patients who underwent revisions of VP shunt for clinical suspicion of shunt infection, and in whom shunt tube and CSF were sent for culture and sensitivity, were further analyzed for the pattern of shunt infection. In our study, the revision of shunt tube with new shunt assembly was only practiced when the same assembly could not be reinserted. Thus, a new shunt assembly was placed in cases where the shunt tube was exposed or there was evidence of redness or swelling over the skin along the shunt tract. In the cases in whom revision of the shunt tube was performed for shunt obstruction because of an omental plug, blood clot or debris, or due to shunt breakage or malposition, the same assembly was reinserted. In the latter situation, therefore, the samples were not sent for any microbiological analysis.

The processing of the samples for culture was done by the standard techniques, and the identification of the organism along with its sensitivity pattern was performed using the Vitek 2 system (Biomerieux). The primary etiology of hydrocephalus, bacterial growth, and changes in the antibiotic sensitivity patterns to various antibiotics were further analyzed reviewing the data obtained over the last 6 years.


 » Results Top


A total of 1186 VP shunts were performed in 6 years from January 2010 to December 2015. There were 756 males (63.8%) and 429 females (36.2%). More than half of these cases (54.4%) were under the age of 10 years [Table 1].
Table 1: Age group and sex ratio of patients undergoing the VP shunt procedure

Click here to view


A total of 259 (21.8%) patients underwent shunt revision with tuberculous meningitis [83 (24.2%)] and pyogenic meningitis [13 (25.4%)] as the leading etiology [Table 2].
Table 2: Causative pathology of hydrocephalus and the total number of VP shunt procedures done with revision and no revision of shunts

Click here to view


According to the criteria defined in the 'Material and Methods' section, the shunt assembly was changed completely or partially (distal or proximal end) in 156 patients, and was sent for microbiological analysis along with the CSF sample.

In 79 (50.6%) patients, there was growth of bacteria in the shunt tubing, or CSF, or both [Table 3]. The maximal growth of bacteria was seen in samples of those patients who had earlier undergone shunt insertion for post-tuberculous hydrocephalus [41 (51.9%)] followed by pyogenic meningitis [Table 4]. In those patients who underwent shunt revision, the cytology and microscopic findings were not suggestive of tuberculosis, hence only an aerobic culture was done (culture for Mycobacterium tuberculosis was not performed). Samples sent for microbiological analysis revealed growth in the CSF only in 36 (23.1%) samples, both in the CSF and shunt tube in 27 (17.3%) samples, and in the shunt tube alone in 16 (10.2%) samples. A single organism was grown in 56 (70.8%) samples and there was polymicrobial growth in 23 (29.1%) samples [Table 5].
Table 3: Year-wise distribution of culture positive cases

Click here to view
Table 4: Distribution of culture positive samples among various aetiology of hydrocephalus

Click here to view
Table 5: Distribution of various samples for growth of organisms

Click here to view


Among the isolates, it was found that Staphylococcus aureus [65 (82.3%)] followed by coagulase-negative Staphylococcus [22 (25.3%)] were the most common isolates, followed by  Escherichia More Details coli, that was isolated from17 (21.5%) samples. In 1 (1.3%) patient, Aspergillus fumigatus was isolated from the scrapings present inside the abdominal end of the shunt tube [Table 6].
Table 6: *Number (percentage) of organisms isolated in culture

Click here to view


The clinical features of patients with shunt revisions whose shunt tubing, CSF, or both, showed growth of an infective organism were retrospectively analyzed. The most common symptom was headache present in 62 (78.5%) patients, followed by vomiting in 60 (75.9%). Other common presenting complaints were fever in 58 (73.4%), decreased consciousness in 50 (63.3%), seizures in 21 (26.6%), redness of skin over the shunt tube in 20 (25.3%), abdominal pain in 13 (16.5%), and blurring of vision in 11 (13.9%) patients [Table 7].
Table 7: Clinical profile of the cases who underwent VP shunt revision

Click here to view


The sensitivity pattern of bacterial organisms revealed that the gram-negative organisms were more sensitive to broad-spectrum antibiotics such as meropenem or imipenem and tigecycline and least sensitive to ticarcillin. The gram-positive bacteria isolated were more sensitive to the broad-spectrum antibiotic, linezolid and least sensitive to roxithromycin.

The trend of antibiotic sensitivity to gram-negative bacteria from 2010 to 2015 showed a decrease in sensitivity to all the quinolones. The average sensitivity to the quinolones in 2015 was only 20%. Similarly, there has been an increasing resistance to all the cephalosporins with an average sensitivity rate of 30–40%. Imipenem, meropenem, and tigecycline have a sensitivity of more than 60%, which has resulted in them becoming the most commonly used antibiotics. Similar trends were seen for quinolones and cephalosporins for gram-positive bacteria, with linezolid and teicoplanin showing sensitivity of more than 60% [Figure 1] and [Figure 2].
Figure 1: Change in sensitivity pattern of Gram-negative bacteria to commonly used antibiotics from 2010 to 2015

Click here to view
Figure 2: Change in sensitivity pattern of Gram-positive bacteria to commonly used antibiotics from 2010 to 2015

Click here to view



 » Discussion Top


Shunt infection poses a major threat in the treatment of hydrocephalus. Early detection and diagnosis of shunt infection is usually difficult because of its nonspecific clinical features. Most of the time, the clinical presentations are the same as that of a shunt malfunction. Headache, vomiting, fever, and progressive deterioration of consciousness were the most common findings among our patients. If the above mentioned signs are present in the postoperative period, VP shunt malfunction should be suspected. In such cases, immediate neuroimaging and CSF studies should be performed to determine whether meningitis is present with shunt malfunction.

The incidence of complications following a VP shunt placement is reported to be in the range of approximately 20–40%.[4],[9],[33] In our study, the complication rate was 21.8%. The complications occurred because of shunt infections, malposition of the ventricular or the abdominal end, blockage of the abdominal end by an omental plug, blockage of the shunt by debris or blood clot, breakage of the shunt assembly, migration of ventricular end of the tube, and exposure or extrusion of the shunt tube.

Postoperative infection of shunts occurs in 2–27% of cases in most neurosurgical units throughout the world.[22],[23],[24],[25],[26],[27] Isolation of bacteria in shunt infection along with determination of their sensitivity pattern is paramount in managing these cases. Shunt revision was done in 21.3% patients, and among the samples sent for microbiological analysis, 79 (50.6%) patients had evidence of bacterial growth. This high incidence was due to the fact that these cases were referred to us from various places, and in many of these patients, the initial surgeries was done at other hospitals. A poor nutritional status appeared to be a common denominator.

The remaining 77 (49.4%) cultures were negative. In these patients, there was either no infection, or infection was present but the organism was resistant to detection and hence did not grow on culture, or there could have been an anaerobic infection (an anaerobic culture was not performed in the study). Another reason for a negative culture could have been because the patient was on antibiotics. While 27 (17.3%) patients had growth of a bacterial organism in the shunt tubing as well as in the CSF, in 36 (23.1%) patients there was growth of bacterial organism only in the CSF, and in 16 (10.2%) patients, the growth occurred in the shunt tubing only. It highlights the fact that CSF may be a better sample to document infection than the shunt tube alone.

In patients undergoing a shunt procedure, the infectious pathogen will most likely be a microorganism from the resident bacterial flora of the skin, nasopharynx, or the external auditory canal. However, the possibility of nosocomial infection should not be ruled out.[34] Many studies have suggested that coagulase-negative staphylococci are the major pathogens in shunt infections, followed by S. aureus.[35],[36],[37],[38] However, Gram-negative bacteria are also responsible for 7–24% of all VP shunt infections.[39],[40] This study demonstrates that S. aureus (82.3%) and coagulase-negative Staphylococcus (25.3%) were the most commonly isolated bacteria. E. coli (21.5%), Klebsiella species (12.7%), and Citrobacter species (7.6%) were the isolated Gram-negative bacteria. Aspiration of gastric contents is common in unconscious patients and is frequently complicated by bacterial superinfection. The routine use of proton pump inhibitors leads to bacterial colonization of the stomach with aerobes, especially the Gram-negative aerobes,[34] which may lead to infections caused by them. A relatively high proportion of mixed infections (14.7%) was detected in our study. Such infections are more complicated and require appropriate antibiotics to eradicate them.

In our study, infections (41 out of 79) and revisions (83 out of 259) were the highest in the post-tuberculous meningitis hydrocephalus group than in other conditions. The reasons for this increase may have been the poor general condition of these patients as well as the presence of higher protein and cellular content of the CSF, leading to more frequent shunt malfunctions. The reported rate of shunt malfunctions in these patients has been 22–43%.[41],[42],[43] An infection rate of 15.6% was reported by Sil and Chatterjee [43] in the cases having tuberculous meningitis.

There has been an alarming rise in the resistance pattern of the Gram-negative bacteria to cephlasporins and quinolones. Aminoglycosides also have shown a decrease in sensitivity. However, imipenem, meropenem, and tigecycline were still sensitive in this group. Similarly, for gram-positive bacteria, the increasing resistance trends to cephalosporins and quinolones is a major concern. However, linezolid and teicoplanin are still sensitive in this group. This may be because of the poor antimicrobial stewardship practices (the antibiotics to which the bacteria are developing resistance are more commonly available in the government hospital supply and are prescribed to patients more often after surgical intervention) prevalent in the hospital. In addition, the patients admitted to our institute are at a high risk of antibiotic resistance due to numerous contacts with hospital fomites and other patients, immunosuppression, and prior exposure to antibiotics.

It is already known that reinserted shunts due to previous infections may have a greater chance of becoming infected.[44],[45] In our study, there was a tendency for a higher infection rate of reinserted shunts due to the existence of prior infections, compared to that of noninfectious causes.


 » Conclusion Top


Shunt infection is a common neurosurgical problem. It can occur in all types of hydrocephalus; however, it is seen more often in the postinfective etiology, in particular tuberculosis. These cases can be difficult to treat because the response to commonly used antibiotics is dismal. Based on our findings of a high prevalence of developing resistance to commonly used antibiotics, we suggest the use of meropenem and teicoplanin with ceftriaxone as an empirical therapy in suspected cases of infections in patients undergoing shunt revision. In addition, because of the changing trends, the specific treatment guidelines should be based on the culture reports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Baru JS, Bloom DA, Muraszko K, Koop CE. John Holter's shunt. J Am Coll Surg 2001;192:79-85.  Back to cited text no. 1
    
2.
Aoyama Y, Kinoshita Y, Yokota A, Hamada T. Neuronal damage in hydrocephalus and its restoration by shunt insertion in experimental hydrocephalus: A study involving the neurofilament-immunostaining method. J Neurosurg 2006;104(5 Suppl):332-9.  Back to cited text no. 2
    
3.
Del Bigio MR. Cellular damage and prevention in childhood hydrocephalus. Brain Pathol 2004;14:317-24.  Back to cited text no. 3
    
4.
Farahmand D, Hilmarsson H, Högfeldt M, Tisell M. Perioperative risk factors for short term shunt revisions in adult hydrocephalus patients. J Neurol Neurosurg Psychiatry 2009;80:1248-53.  Back to cited text no. 4
    
5.
Kandasamy J, Dwan K, Hartley JC, Jenkinson MD, Hayhurst C, Gatscher S, et al. Antibiotic-impregnated ventriculoperitoneal shunts — A multi-centre British pediatric neurosurgery group (BPNG) study using historical controls. Childs Nerv Syst 2011;27:575-81.  Back to cited text no. 5
    
6.
Lee L, King NK, Kumar D, Ng YP, Rao J, Ng H, et al. Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: A retrospective study with cost–benefit analysis. J Neurosurg 2014;121:899-903.  Back to cited text no. 6
    
7.
Lemcke J, Meier U. Improved outcome in shunted iNPH with a combination of a Codman Hakim programmable valve and an Aesculap-Miethke Shunt Assistant. Cent Eur Neurosurg 2010;71:113-6.  Back to cited text no. 7
    
8.
Lemcke J, Meier U, Müller C, Fritsch M, Eymann R, Kiefer M, et al. Is it possible to minimize overdrainage complications with gravitational units in patients with idiopathic normal pressure hydrocephalus? Protocol of the randomized controlled SVASONA Trial (ISRCTN51046698). Acta Neurochir Suppl 2010;106:113-5.  Back to cited text no. 8
    
9.
Reddy GK, Bollam P, Caldito G. Long-term outcomes of ventriculoperitoneal shunt surgery in patients with hydrocephalus. World Neurosurg 2014;81:404-10.  Back to cited text no. 9
    
10.
Sciubba DM, Noggle JC, Carson BS, Jallo GI. Antibiotic-impregnated shunt catheters for the treatment of infantile hydrocephalus. Pediatr Neurosurg 2008;44:91-6.  Back to cited text no. 10
    
11.
Borgbjerg BM, Gjerris F, Albeck MJ, Hauerberg J, Børgesen SE. Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir (Wien) 1995;136:189-94.  Back to cited text no. 11
    
12.
Cochrane DD, Kestle JR. The influence of surgical operative experience on the duration of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg 2003;38:295-301.  Back to cited text no. 12
    
13.
Di Rocco C, Marchese E, Velardi F. A survey of the first complication of newly implanted CSF shunt devices for the treatment of nontumoral hydrocephalus. Cooperative survey of the 1991–1992 Education Committee of the ISPN. Childs Nerv Syst 1994;10:321-7.  Back to cited text no. 13
    
14.
Farahmand D, Hilmarsson H, Högfeldt M, Tisell M. Perioperative risk factors for short term shunt revisions in adult hydrocephalus patients. J Neurol Neurosurg Psychiatry 2009;80:1248-53.  Back to cited text no. 14
    
15.
McGirt MJ, Buck DW 2nd, Sciubba D, Woodworth GF, Carson B, Weingart J, et al. Adjustable vs set-pressure valves decrease the risk of proximal shunt obstruction in the treatment of pediatric hydrocephalus. Childs Nerv Syst 2007;23:289-95.  Back to cited text no. 15
    
16.
Notarianni C, Vannemreddy P, Caldito G, Bollam P, Wylen E, Willis B, et al. Congenital hydrocephalus and ventriculoperitoneal shunts: Influence of etiology and programmable shunts on revisions. J Neurosurg Pediatr 2009;4:547-52.  Back to cited text no. 16
    
17.
Stein SC, Guo W. Have we made progress in preventing shunt failure? A critical analysis. J Neurosurg Pediatr 2008;1:40-7.  Back to cited text no. 17
    
18.
Tuli S, Drake J, Lawless J, Wigg M, Lamberti-Pasculli M. Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 2000;92:31-8.  Back to cited text no. 18
    
19.
Wu Y, Green NL, Wrensch MR, Zhao S, Gupta N. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery 2007;61:557-63  Back to cited text no. 19
    
20.
Kestle J, Drake J, Milner R, Sainte-Rose C, Cinalli G, Boop F, et al. Long-term follow-up data from the Shunt Design Trial. Pediatr Neurosurg 2000;33:230-6.  Back to cited text no. 20
    
21.
Blount JP, Campbell JA, Haines SJ. Complications in ventricular cerebrospinal fluid shunting. Neurosurg Clin N Am 1993;4:633-56.  Back to cited text no. 21
    
22.
Bhatnagar V, George J, Mitra DK, Upadhyaya P. Complications of cerebrospinal fluid shunts. Indian J Pediatr 1983;50:133-8.  Back to cited text no. 22
[PUBMED]    
23.
Kaufman BA, Mc Lone DG. Infection of cerebrospinal fluid shunts. In: Scheld WM, Whitley RJ, Durack DT (editors). Infection of the Central Nervous System. Raven Press: New York; 1991. pp. 561-85.  Back to cited text no. 23
    
24.
Morrice JJ, Young DG. Bacterial colonization of Holter valves: A ten-year survey. Dev Med Child Neurol 1974;16(Suppl 32):85-90.  Back to cited text no. 24
    
25.
Olsen L, Frykberg T. Complications in the treatment of hydrocephalus in children. A comparison of ventriculoatrial and ventriculoperitoneal shunts in a 20-year material. Acta Pediatr Scand 1983;72:385-90.  Back to cited text no. 25
    
26.
Schoenbaum SC, Gardner P, Shillito J. Infections of the cerebrospinal fluid shunts: Epidemiology, clinical manifestation, and therapy. J Infect Dis 1975;131:543-52.  Back to cited text no. 26
[PUBMED]    
27.
Sells CJ, Shurtleff DB, Loeser JD. Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics1977;59:614-8.  Back to cited text no. 27
[PUBMED]    
28.
Singh A, Vajpeyi I N. Comparative study of lumboperitoneal shunt versus ventriculoperitoneal shunt in post meningitis communicating hydrocephalus in children. Neurol India 2013;61:513-6  Back to cited text no. 28
    
29.
Holt RJ. Bacteriological studies in colonized ventriculoatrial shunts. Dev Med Child Neurol Suppl 1970;22(Suppl 22):83-7.  Back to cited text no. 29
    
30.
Ersahin Y, McLone DJ, Storrs BB, Yogev R. Review of 3017 procedures for the management of hydrocephalus in children. Concepts Pediatr Neurosurg 1989;9:21-8.  Back to cited text no. 30
    
31.
McGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 2003;36:858-62.  Back to cited text no. 31
    
32.
Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: A prospective study of risk factors. J Neurosurg 2001;94:195-201.  Back to cited text no. 32
    
33.
Al-Tamimi YZ, Sinha P, Chumas PD, Crimmins D, Drake J, Kestle J, et al. Ventriculoperitoneal shunt 30-day failure rate: A retrospective international cohort study. Neurosurgery 2014;74:29-34.  Back to cited text no. 33
    
34.
Aubert G, Jacquemond G, Pozzetto B, Duthel R, Baylot D, Brunon J, et al. Pharmacokinetic evidence of imipenem efficacy in the treatment of Klebsiella pneumonae nosocomial meningitis. J Antimicrob Chemother 1991;28:316-7.  Back to cited text no. 34
    
35.
Odio C, McCracken GH Jr, Nelson JD. CSF shunt infections in pediatrics. A seven-year experience. Am J Dis Child 1984;138:1103-8.  Back to cited text no. 35
[PUBMED]    
36.
Enger PØ, Svendsen F, Sommerfelt K, Wester K. Shunt revisions in children — Can they be avoided? Experiences from a population-based study. Pediatr Neurosurg 2005;41:300-4.  Back to cited text no. 36
    
37.
Kontny U, Höfling B, Gutjahr P, Voth D, Schwarz M, Schmitt HJ. CSF shunt infections in children. Infection 1993;21:89-92.  Back to cited text no. 37
    
38.
McGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis 2003;36:858-62.  Back to cited text no. 38
    
39.
Stamos JK, Kaufman BA, Yogev R. Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 1993;33:858-62.  Back to cited text no. 39
    
40.
Wang KC, Lee HJ, Sung JN, Cho BK. Cerebrospinal fluid shunt infection in children: Efficiency of management protocol, rate of persistent shunt colonization, and significance of 'off-antibiotics' trial. Childs Nerv Syst 1999;15:38-44  Back to cited text no. 40
    
41.
Palur R, Rajshekhar V, Chandy MJ, Joseph T, Abraham J. Shunt surgery for hydrocephalous in tubercular meningitis: A long-term follow-up study. J Neurosurg 1991;74:64-9.  Back to cited text no. 41
    
42.
Agrawal D, Gupta A, Mehta VS. Role of shunt surgery in pediatric tubercular meningitis with hydrocephalus. Indian Pediatr 2005;42:245-50.  Back to cited text no. 42
    
43.
Sil K, Chatterjee S. Shunting in tuberculous meningitis: A neurosurgeon's nightmare. Childs Nerv Syst 2008;24:1029-32.  Back to cited text no. 43
    
44.
Kestle JR, Garton HJ, Whitehead WE, Drake JM, Kulkarni AV, Cochrane DD, et al. Management of shunt infections: A multicenter pilot study. J Neurosurg 2006;105(3 Suppl):177-81.  Back to cited text no. 44
    
45.
Kulkarni AV, Rabin D, Lamberti-Pasculli M, Drake JM. Repeat cerebrospinal fluid shunt infection in children. Pediatr Neurosurg 2001;35:66-71.  Back to cited text no. 45
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

This article has been cited by
1 Neuroendoscope: Evolving Spectrum of Utility in the Management of Hydrocephalus, Biopsy, and Resection of Ventricular Tumors and Cyst Fenestration
Guru Dutta Satyarthee
World Neurosurgery. 2017; 104: 1029
[Pubmed] | [DOI]
2 Controversy about Management of Hydrocephalus – Shunt vs. Endoscopic Third Ventriculostomy
Vikas Kumar,Shaam Bodeliwala,Daljit Singh
The Indian Journal of Pediatrics. 2017; 84(8): 624
[Pubmed] | [DOI]
3 Nonalcoholic fatty liver disease with cirrhosis increases familial risk for advanced fibrosis
Cyrielle Caussy,Meera Soni,Jeffrey Cui,Ricki Bettencourt,Nicholas Schork,Chi-Hua Chen,Mahdi Al Ikhwan,Shirin Bassirian,Sandra Cepin,Monica P. Gonzalez,Michel Mendler,Yuko Kono,Irine Vodkin,Kristin Mekeel,Jeffrey Haldorson,Alan Hemming,Barbara Andrews,Joanie Salotti,Lisa Richards,David A. Brenner,Claude B. Sirlin,Rohit Loomba
Journal of Clinical Investigation. 2017; 127(7): 2697
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow