Elsevier

World Neurosurgery

Volume 129, September 2019, Pages 34-44
World Neurosurgery

Literature Review
Diagnosis of Ventricular Shunt Infection in Children: A Systematic Review

https://doi.org/10.1016/j.wneu.2019.05.057Get rights and content

Background

No widely accepted gold standard for diagnosis of shunt infection exists, with definitions variable among clinicians and publications. This article summarizes the utility of commonly used diagnostic tools and provides a comprehensive review of optimal measures for diagnosis.

Methods

A query of PubMed was performed extracting articles related to shunt infection in children. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, resulting in 1756 articles related to shunt infection, 49 of which ultimately met inclusion criteria.

Results

Of the 49 articles included in the analysis, 9 did not define infection, 9 used culture alone, 9 used cultures and/or symptomatology, and 4 used a combination of cultures, cerebral spinal fluid (CSF) pleocytosis and symptomatology. The remainder of the studies used definitions from the Centers for Disease Control and Prevention (n = 2) and the Hydrocephalus Clinical Research Network (n = 2) or borrowed elements from these definitions. Variation in definition stems from the lack of sensitivity and specificity of commonly used signs, symptoms, and tests. Shunt tap alone is considered half as sensitive as hardware culture. Fever upon presentation was present in 16% to 42% of cases. CSF pleocytosis combined with fever has a sensitivity of 82% and specificity of 99%. CSF eosinophilia, lactic acid, serum anti-Staphylococcus epidermidis titer, procalcitonin, and C-reactive protein are non-specific and their utility is not well established.

Conclusions

The definition of shunt infection is variable across studies, with CSF culture and/or symptomatology being the most commonly utilized parameters.

Introduction

More than 40,000 cerebrospinal fluid (CSF) shunts are placed annually in the United States and approximately 2300 become infected; yet, there is no consensus on the parameters defining shunt infection.1 Overt meningitis with positive CSF cultures, exposed hardware, abscess formation, incisional rubor, calor, dolor, and tumor are clear indications for treatment; however, infection is often subtle and may be difficult to distinguish from primary shunt malfunction. Delayed diagnosis in such cases may lead to prolonged morbidity, mortality, and recurrent shunt failure.

Current United States data specific to shunt infection are not available. The latest Centers for Disease Control and Prevention (CDC) data for elective neurosurgical procedures was reported in 2004, which includes only perioperative and not delayed infections. In 2003, shunt infection resulted in an estimated $250 million of hospital charges.1 Published infection rates vary from 0.33% to 41%, with recent studies reporting between 1% and 6% risk per procedure (Table 1).

Proposed consequences of shunt infection include malfunction, seizure, decreased cognitive function, morbidity, mortality, prolonged hospitalization, and the associated sequela including emotional distress and economic loss.25, 50, 51 Associations between decreased intelligence quotient and shunt infection may be secondary to prolonged hospitalization resulting in decreased school performance.25, 51 The psychological, financial, and emotional burden is indisputable. The aim of this review is to provide a concise, yet thorough review of the published definitions of shunt infection.

Section snippets

Methods

Information sources include MEDLINE, infectious disease and neurological surgery authoritative textbook review, and expert opinion. MEDLINE was queried with the following search ([{diagnosis (Title/Abstract)} OR treatment (Title/Abstract)] AND shunt infection (Title/Abstract)) NOT dialysis [Title/Abstract]. This resulted in 1476 results screened by title and abstract for relevant articles (Figure 1). Additional articles were obtained by citation review.

Articles were excluded after review of

Definition of Shunt Infection

Of the 49 articles included in the analysis, 9 did not define infection, 9 used cultures alone, 9 used cultures and/or symptomatology, and 4 used a combination of cultures, CSF pleocytosis, and symptomatology. The remainder of the studies used definitions by the CDC (n = 2), Hydrocephalus Clinical Research Network (HCRN, n = 2) or borrowed elements from these definitions (Table 1).

The CDC definition of ventriculitis/meningitis is inclusive and takes culture, signs, symptoms, vitals, and patient

Pathogenesis

The majority of shunt infections occur at the time of implantation resulting from contamination with commensal organisms in the patients nose, ears, and skin.69 Immediately after skin preparation with iodine scrub, 31% of skin swabs were found to be positive and 25% of wounds were contaminated after incision.70 Thus, coagulase negative staphylococci, S aureus and P acnes are the most common infecting organisms (Table 6). One study found that 59% of wounds and 65% of the irrigation solutions

Conclusion

There is currently no generally accepted definition for shunt infection. Unlike with other catheter infections, colonization can lead to malfunction even without other systemic manifestations, which is why sample preparation that detects biofilms may be important. Less virulent infections may manifest as shunt malfunction or systematic disease. Further research into the relationship between biofilm detection and shunt malfunction may be needed to develop an accurate gold standard. At this time,

Acknowledgments

We thank Henry Ford Hospital Sladen Library services for assistance in literature review; Marcus M. Zervos, M.D., infectious disease clinician, and Cynthia Chen, M.D., emergency medicine clinician, for content review; and Susan MacPhee for editorial review.

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    Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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