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Antibiotic impregnated external ventricular drainage and third ventriculostomy in the management of hydrocephalus associated with posterior cranial fossa tumours

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Abstract

Background

The effectiveness of antibiotic pre-treated ventricular catheters in reducing the risk of CSF infections (determined on CSF cultures) resulting from the use of per-operative external ventricular drainages (EVD) and the success rate of post-operative endoscopic third ventriculostomy (ETV) in the management of persistent hydrocephalus after posterior cranial fossa tumour removal are assessed.

Method

Forty-seven children (group I) were prospectively managed by means of per-operative antibiotic impregnated EVD, post-operative ICP monitoring, and ETV. The results of this group were compared with those of a control group composed by 44 children treated with the same protocol as above except for the use of not-impregnated catheters (group II).

Findings

The rate of positive CSF cultures due to EVD resulted significantly lower in group I (2.1% vs 31.8%); there was no clinical evidence of CSF infections. The success rate of ETV was the same in both groups (75%). Failures of ETV occurred in the patients with subarachnoid tumour seeding and/or tumour extension to the basal cisterns. All the children of group II with failed ETV also showed a bacterial growth in the CSF.

Conclusions

Antibiotic pre-treated catheters in our experience considerably limited EVD-related bacterial growth in the CSF. Preoperative hydrocephalus resolved in 60% of the cases after tumour removal, thus confirming recent data from the literature against the routine use of preoperative ETV. In our experience postoperative ETV had a high success rate; poor results were obtained in children with tumour seeding and/or the evidence of positive CSF cultures.

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Financial disclosure

The authors declare they do not have any financial interest in the materials presented and discussed in this paper.

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Authors and Affiliations

  1. Paediatric Neurosurgery, Institute of Neurosurgery, Catholic University Medical School, Largo “A. Gemelli”, 8, 00168, Rome, Italy

    Gianpiero Tamburrini, Luca Massimi, Massimo Caldarelli & Concezio Di Rocco

Authors
  1. Gianpiero Tamburrini
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  2. Luca Massimi
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  3. Massimo Caldarelli
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  4. Concezio Di Rocco
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Corresponding author

Correspondence to Luca Massimi.

Additional information

Comment

This MS compares two groups of children with tumours. In both groups the patients received post - craniotomy EVD for pressure monitoring and CSF sampling. In Group 1, all received an antimicrobial EVD while the historical control Group 2 received a plain catheter. In terms of infective complications, study outcomes were infection rate, the need for EVD revision and hospital stay related to infection management. The policy for both groups included CSF sampling every 2 days, and immediate catheter replacement when a positive culture was reported. Probably because of this, no cases of clinical CSF space infection were seen in either group. However, the "infection" rates in Groups 1 and 2 were 2.1% and 31.8% respectively. Sampling of CSF during EVD without clinical indication (eg fever) is held to be a risk for infection. However, the findings here raise questions about this, and suggest that, if done with proper precaution, it might be clinically advantageous. The authors have reported a sequential study with historical controls, yet the results in terms of infection prevention are interesting. Prospective randomised controlled trials, with sufficient patients, are needed, as the authors say.

Dr Roger Bayston

University of Nottingham

Comment

This group have provided further information to a growing body of knowledge with respect to the use of antimicrobial impregnated catheters in reducing, and virtually eliminating infective complications. An interesting, unexplained observation is that in patients in which this particular technology has been used, there appears to be a general reduction of infective complications, including organisms not known to be particularly susceptible to the specific antimicrobial agents employed in this group of catheters. This may be an interesting area of future study. A further area of interest is the use of silver impregnation technology which extends the range of organism susceptibility.

Reduction of infections in children who have a documented higher infection risk in foreign material use is a high priority. Collecting information of sufficient statistical power a further challenge.

Van Dellen

Charing Cross Hospital, London

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Tamburrini, G., Massimi, L., Caldarelli, M. et al. Antibiotic impregnated external ventricular drainage and third ventriculostomy in the management of hydrocephalus associated with posterior cranial fossa tumours. Acta Neurochir (Wien) 150, 1049–1056 (2008). https://doi.org/10.1007/s00701-008-0022-6

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  • DOI: https://doi.org/10.1007/s00701-008-0022-6

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