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Infecciones relacionadas con Derivacin Ventricular ExternaYuri Vladimir Valdivieso VillenaMdico Residente NeurocirugaHNAAA

Ventriculitisdebe cumplir almenosunode los siguientes criterios:Organismoscultivadosa partirdel lquidocefalorraqudeo(LCR).El paciente tienealmenos 1de lossiguientes signos osntomassinotra causa:fiebre(>38 C ),dolor de cabeza,rigidez de nuca,signosmenngeos,,oirritabilidad y por lomenosunade lassiguientes :Aumento deglbulos blancos, protenaselevadasy/odisminucin dela glucosaen el lquido cefalorraqudeo.

Organismosvistoen latincin de GramdelLCR.

Organismoscultivadosdela sangre

Pruebadel antgenopositivodeLCR,sangreu orina

Diagnsticonicottulode anticuerpos(IgM)oaumento de 4vecesensuerospareados(IgG)parapatgenos

hidrocefalias agudashemorragias intraventriculares medicin de PIC administracin de frmacos intraventricularesfstulas de LCR (postquirrgicas o traumticas) infecciones de shunts: paso intermedio

Ventriculitis Asociada a DVEINCIDENCIA 0 % a 22 %, en la mayora comnmente, la incidencia es inferior al 10 %.Tasas ms altas del 10 % debe dar lugar a examinar la estructura de protocolos institucionales.

Current Concepts and Approach to Ventriculitis Amit Agrawal, MCh,* Rafael Cincu, MD, PhD,y and Jake Timothy, MBBS, MD, FRCSz.Infectious Diseases in Clinical Practice Volume 16, Number 2, March 2008VARIABILIDAD:Poblacin hetergeneaCriterios clnicos utilizados

Incidencia depende de :Tcnica Insercin del catter ventricularManejo clnico posterior

Management of Nosocomial External Ventricular Drain-Related Ventriculomeningitis. Beer R, et .Neurocrit Care 2009; 10 (3): 363-7.VENTRICULITIS ASOCIADAS A DVE: FACTORES DE RIESGOHemorragia intraventricular o subaracnoideaUtilizacin varios DVE Manipulaciones repetidas Sistemas abiertos Infecciones concomitantes en otro lugarEl tiempo de drenaje.

Hoefnagel D, et al. Acta Neurochir (Wien) 2008; 150 (3); 209-14Lozier AP, et. Neurosurgery 2002; 51: 170-82.DIAGNSTICOCLINICO :Deterioro del nivel de concienciaFIEBRE CAMBIO EN EL ASPECTO DEL LCRCLNICA DE HIDROCEFALIA (cefalea, vmitos) por obstruccin del drenajeConvulsiones Signos inflamatorios y/o exudacin purulenta en el trayecto tunelizado o por el orificio de salida del catter.

Jimnez-Mejas ME, et al. Enferm Infecc Microbiol Clin 2008; 26 (4): 240-251La temperatura y la GCS no son predictores confiables de ventriculitis en pacientes con EVD

EX. AUXILIARESTincion de GramCitoquimico :

glucosa en LCR < 25 mg / dl en el LCR nivel de protenas > 50 mg / dl , neutrfilos pleocitosis > 10 clulas / ml .

Current Concepts and Approach to Ventriculitis Amit Agrawal, MCh,* Rafael Cincu, MD, PhD,y and Jake Timothy, MBBS, MD, FRCSz.Infectious Diseases in Clinical Practice Volume 16, Number 2, March 2008LACTATO en LCR:>4.0 mmol/L. Sensibilidad: 88%, Especificidad: 98%; VPP:96%; VPN:94%.Gran valor en esta Subpoblacin ya que los diferentes marcadores bioqumicos del LCR ( leucocitos, Gram, glucosa, proteina en LCR) no M. Bacteriana vs M. Asptica.

Tunkel A, et al. Clinical Infectious Diseases 2004; 39: 1267-84. MeisnerM. Current Opinion in Critical Care 2005; 11(5): 473-480CONTAMINACIN DEL CATTER: Un cultivo aislado de LCR y/o gram sin signos clnicos o bioqumicos de infeccin.COLONIZACIN DEL CATTER: Ms de un cultivo (+) y/o gram al mismo microorganismo, sin signos clnicos o bioqumicos de infeccin. SOSPECHA INFECCIN VENTRICULAR ASOCIADA A DVE:No cultivo o Gram de LCR positivos + alteraciones bioqumicas

Lozier AP, et. Neurosurgery 2002; 51: 170-82.INFECCIN RELACIONADA DVE:1 cultivo o tincin de Gram del LCR positivos + alteraciones bioqumicas + sintomatologa clnica leve (fiebre)VENTRICULITIS:1 cultivo o Gram del LCR positivos + alteraciones bioqumicas +sintomatologa clnica (fiebre alta, meningismo, fotofobia,disminucin de consciencia, convulsiones)

Lozier AP, et. Neurosurgery 2002; 51: 170-82.

MANEJOUno de los pilares ms importantes en el tratamiento es la administracin de agentes antimicrobianos que sean capacez de alcanzar concentraciones efectivas en el LCR y tejido cerebralTRATAMIENTO EMPRICOLa eleccin del tratamiento antimicrobiano emprico en ventriculitis debe regirse por la edad del paciente y por varias condiciones que pueden haber predispuesto al paciente a ventriculitis ( postraumtico, la desviacin asociada al catter, inmunosupresion,etc ).

Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39: 12671284

TRATAMIENTO ESPECFICORecomendaciones para los antimicrobianos la terapia en pacientes con presunta identificacin de patgenos por tincin de Gram, basada en la edad del paciente y condicin especfica predisponente, y en base a patgenos aislados.CefalosporinasCeftazidima, ha demostrado su eficacia en varios estudios de los pacientes infx. por Pseudomonas.Una cefalosporina 4ta G. cefepima, ha demostrado ser seguro y teraputicamente equivalente a la cefotaxima en el tratamiento de ventriculitis en nios, tiene mayor actividad in vitro que las cefalosporinas 3era G. frente a especies de Enterobacter y Pseudomonas aeruginosa.

Rousseau JM, Soullie B, Villevielle T, et al. Efficacy of cefepime in postoperative meningitis attributable to Enterobacter aerogenes.J Trauma. 2001;50:971AMINOGLUCSIDOSLa amikacina, administrada sistemticamente a los pacientes con ventriculitis, alcanza niveles en el LCR o el lquido ventricular que inhiben o matan a muchas de las bacterias gram-negativas comunes que causan infecciones del sistema nervioso central. Terapia sistmica con amikacina puede ser el tratamiento de eleccin para los nios con ventriculitis.

Yogev R, Kolling WM. Intraventricular levels of amikacin after intravenous administration. Antimicrob Agents Chemother. 1981;20(5):583586VancomicinaLa vancomicina se debe combinar con una cefalosporina tercera generacin y no debe utilizarse como un solo agente. Debe administrarse para mantener las concentraciones de suero aproximadamente 15 a 20 mg / ml. La administracin intratecal de vancomicina puede ser considerarse en pacientes que no responden a parenteral la administracin.RifampicinaLa rifampicina tiene muchas propiedades: as como las buena penetracin LCR y la actividad in vitro contra muchos patgenos menngeos. Sin embargo,, desarrolla resistencia rpidamente, de manera que la rifampicina debe utilizarse en combinacin con otros agentes antimicrobianos. La rifampicina slo se debe aadir si el organismo se demuestra que es susceptible .Debe combinarse con vancomicina en pacientes con infecciones de la derivacin del LCR causada por estafilococos, especialmente en los casos en los que la derivacin no se puede quitarQuinolonasCiprofloxacino penetra en el LCR de pacientes y tiene un muy amplio espectro de actividad antibacteriana incluyendo mayora de los organismos responsables de ventriculitis, con la excepcin Streptococcus pneumoniae.Ofloxacina fcilmente se difunde en el LCR de pacientes ventriculitis, y las concentraciones en el LCR exceden la CIM.

Issacs D, Slack MPE, Wilkinson AR, et al. Successful treatment of Pseudomonas ventriculitis with ciprofloxacin. J Antibicrob Chemother.1986;17:535538.Pioget JC, Wolff M, Singlas E, et al. Diffusion of ofloxacin into cerebrospinal fluid of patients with purulent meningitis or ventriculitis. Antimicrob Agents Chemother. 1989;33(6):933936.

TRATAMIENTO ANTIMICROBIANO INTRATECALInfeccin asociada a un drenaje o ventriculitis donde no existen alternativas sistmicas disponibles y donde a pesar del TTO. sistmica no hay mejora del paciente o esterilizacin del LCR.Tto. Infeccin asociada a DVE cuando no es posible plantear su eliminacin o reemplazo.NO APROBADO POR FDAUso PROFILCTICO AB INTRATECALES (DVE): NO DEMOSTRADO.Ziai W, et. Curr Opin Neurol 2009; 22: 277-282No reemplaza terapia sistmica. Administrar diluidos en solucin salina al 9% estril.Volumen administrar 2-5 ml Interrrumpir el circuito de 1 a 3 horas. DOSIS: COCIENTE INHIBIDOR EN EL LCR>10 (concentracin del frmaco en el LCR/CMI del germen)Ziai W, et. Curr Opin Neurol 2009; 22: 277-282.1. Vancomicina 20 mg/da.2. Gentamicina 5-10 mg /da3. Amikacina 30 mg/da4. Teicoplanina: 5-40 mg/da5. Quinupristin/dalfopristin: 2-5 mg/da6. Daptomicina 10 mg/ 72 horas7. Polimixina B: 5 mg/da8. Colistina: 10 mg/daCefalosporinas, anfotericina B y otros antimicrobianos (no se recomiendan)Lpez-Alvrez B, et al. Acta Neurochir (Wien) 2009; 151 (11):1465-1472

Fact de riesgo reportados son inconsistentes y controversiales466 px - 739 operaciones (1.59 promedio) promedio de 5 aos de edad, 54% hombres, Falla 24.1% al da 90 y 29.9% al da 180.No hubo factores que demostraran diferencia al da 90 y al 180.31

(VS sphilococcus epidermidis) Cateteres baados pierden su efecto a los 2 dias excepto la rifampicina q lo hace a los 9 das.No han demostrado impacto en reducir el riesgo de infeccin.32

La Proteina C reactiva debe ser incluida en la primera line de examenes de pacientes con sospecha de infeccion de LCR, lo que permitira evitar tomar muestra de LCR en px con PCR < 7mg/L; Sensib: 97.1%, Especif: 73.5% VPN: 97.3%.

Object. Shunt infections and their management remain a clinically important problem in patients with hydrocephalus.The authors evaluated, in comparison with traditional parameters, C-reactive protein (CRP) in blood/serum (SCRP)and in cerebrospinal fluid (CSF; C-CRP) for its power to identify and treat patients with infected shunts.Methods. On 84 different occasions, CSF and blood samples from 59 children suspected of having shunt/CSF infectionswere obtained and evaluated. An infection was proven by a CSF culture in 35 of 84 evaluations. Values forS-CRP in infected individuals were higher than in noninfected ones (91.8 6 70.2 mg/L compared with 16.1 6 28.3mg/L, p , 0.0001). The sensitivity of S-CRP testing was 97.1%, the specificity 73.5%, the negative predictive value97.3%, and the receiver operating characteristic area 91.6%. The probability of shunt/CSF infectionprovided thatthe S-CRP level was greater than 7 mg/Lrose from 41.7% (prevalence) to a posttest level of 72.3%. Specificityand posttest probability were 87.8 and 87.2%, respectively, if cases with other concurrent infections were excluded.The probability of missing a CSF/shunt infection at an S-CRP lower than 7 mg/L was 2.7%. All other diagnosticparameters did not yield useful test results. The rate of reinfection was elevated in patients in whom S-CRP levelswere greater than 7 mg/L at the time of shunt reimplantation.Conclusions. Analysis of these data suggests that the S-CRP level should be included in the first-line workup ofpatients with suspected shunt/CSF infection. It seems justified to avoid performing a shunt tap if S-CRP levels areless than 7 mg/L. A larger multicenter trial is necessary to confirm these promising diagnostic results and to deliverhard data concerning whether or not a normalized S-CRP level is a reliable indicator of successful antibiotic therapyand whether a shunt can be safely reimplanted.33

El riesgo de infeccin es muy remoto si el procedimiento es realizado correctamente.

Object. Most CSF-diverting shunt systems have an access port that can be percutaneously tapped. Tapping theshunt can yield valuable information as to its function and whether an infection is present. The fear of causing a shuntinfection by tapping may limit the physicians willingness to do so. The authors of this study investigate the risk ofinfecting a shunt secondary to percutaneous tapping.Methods. Following institutional review board approval, CSF specimens obtained from tapping an indwellingCSF-diverting shunt during the 2011 and 2012 calendar years were identified and matched with clinical information.A culture-positive CSF sample was defined as an infection. If results were equivocal, such as a broth-onlypositiveculture, a repeat CSF specimen was examined. The CSF was obtained by tapping the shunt access port with a25-gauge butterfly needle after prepping the unshaven skin with chlorhexidine.Results. During the study period, 266 children underwent 542 shunt taps. With 541 taps, no clinical evidence ofa subsequent shunt infection was found. One childs CSF went from sterile to infected 11 days later; however, thispatient had redness along the shunt tract at the time of the initial sterile tap.Conclusions. The risk of infection from tapping a shunt is remote if the procedure is done correctly.

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Object. In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introducedto the United Kingdom (UK) market.

These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis.

The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design.

Methods. The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures.

The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known aboutdiagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures.

Results. Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test).

Conclusions. The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.

47 vs 30 de 994 px fueron infectados.????Tiene el potencial de reducir las infecciones??35

Object. The objective of this investigation was to review the clinical characteristics of recurrent CSF shunt infectionsin a large pediatric neurosurgical practice and to assess the safety and efficacy of reusing original ventricularentry sites for external ventricular drainage during treatment of infections and for subsequent reinsertion of shunts.

Methods. Prospectively accrued clinical data on all patients treated at Childrens Hospital Colorado for CSFshunt infections within a 10.5-year span were retrospectively investigated.

Results. One hundred twenty-one consecutive cases of CSF shunt infection met inclusion criteria. Recurrentshunt infection attributable to the management of these infections occurred in 14 cases (11.6%). Three recurrentinfections were with their original organisms, 7 were organisms different from the original organisms, and 4 wereindeterminate.

Conclusions. Half or more of recurrent shunt infections were with organisms different from the original organism,and hence were new-type infections introduced during the management of the original infections. Incompleteeradication of original pathogens accounted for 3 (21.4%) of the 14 recurrent infections. Reusing recently infected orcontaminated ventricular entry sites, both for CSF drainage during treatment and for implantation of new shunts, wasas safe, with regard to risk of recurrent infection, as switching to new entry sites. Prior evidence of shunt infection isnot, alone, a sufficient reason to change to a previously well-functioning site, and reuse of contaminated ventricularentry sites avoids all risks associated with making new ventricular entries.

Se estudio 121 px de los que 14 desarrollaron infecc recurrente.3 con el mismo org7 diferente org4 indeterinadoMs de la mitad son por org diferentes.Cc: Es vlido utilizar la misma entrada.

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1036 px 103 desarrllo infeccion33 (32%) tuvo revisiones previas0-1 revisin HR 3.9> 2 rev HR 13

Otros Fx de Rx:Gastrostoma HR 2.06-12m de edad HR 0.3NQX previa HR 0.4

ObjectiveTo quantify the extent to which revision(s) of cerebrospinal fluid (CSF) shunt areassociated with increased risk of CSF shunt infection, after adjusting for patient factors that maycontribute to infection risk.Study designWe used the HCRN registry to assemble a large prospective six center cohort of1,036 children undergoing initial CSF shunt placement between April 2008 and January 2012. Theprimary outcome of interest was first CSF shunt infection. Data for initial CSF shunt placementand all subsequent CSF shunt revisions prior to first CSF shunt infection, where applicable, wereobtained. The risk of first infection was estimated using a multivariable Cox proportional hazardmodel accounting for patient characteristics and CSF shunt revisions, and is reported using hazardratios (HR) with 95% confidence intervals (CI).ResultsOf the 102 children who developed first infection within 12 months of placement, 33(32%) followed one or more CSF shunt revisions. Baseline factors independently associated withrisk of first infection included: gastrostomy tube (HR 2.0, 95% CI: 1.1, 3.3), age 612 months (HR0.3, 95% CI: 0.1, 0.8), and prior neurosurgery (HR 0.4, 95% CI: 0.2, 0.9). After controlling forbaseline factors, infection risk was most significantly associated with the need for revision (1revision vs. none, HR 3.9, 95% CI: 2.2, 6.5; 2 revisions, HR 13.0, 95% CI: 6.5, 24.9).ConclusionsThis study quantifies the elevated risk of infection associated with shuntrevisions observed in clinical practice. To reduce risk of infection risk further work shouldoptimize revision procedures.37

Shunt surgery after external ventricular drainage (with or without prior infection) had the highestinfection rate.

Infections were defined on the basis of CSF, wound, or pseudocyst cultures; woundbreakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrialshunt.

El uso de cateter impregnado y el uso de un gel antibacterial por todo el equipo redujo el riesgo de infecciones.

ObjectQuality improvement techniques are being implemented in many areas of medicine. Inan effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol wasdeveloped and implemented at 4 centers of the Hydrocephalus Clinical Research Network(HCRN).MethodsThe protocol was developed sequentially by HCRN members using the currentliterature and prior institutional experience until consensus was obtained. The protocol wasprospectively applied at each HCRN center to all children undergoing a shunt insertion or revisionprocedure.

Procedures and infections were measured before and after protocol implementation.ResultsTwenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007,and February 28, 2009. The minimum follow-up was 6 months. The Network infection ratedecreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absoluterisk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate.

Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.193.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53,95% CI 1.4314.41; p = 0.01) were associated with an increased risk of infection.

ConclusionsThe standardized protocol for shunt surgery significantly reduced shunt infectionacross the HCRN. Overall protocol compliance was good. The protocol has established a commonbaseline within the Network, which will facilitate assessment of new treatments. Identification offactors associated with infection will allow further protocol refinement in the future.38

If not controlled in the early stage, ventriculitis is difficult to treat neurosurgically and can lead to serious sequelae, a long course of treatment, and hospitalization. We report two cases of ventriculitis and progressive hydrocephalus after shunt infection. Both were successfully treated by neuroendoscopic septostomy in combination with thorough intraventricularirrigation through a single burr hole followed by single shunt revision.

Although surgical intervention has not been established as a first-choice treatment for ventriculitis, including early-stage ventriculitis, prompt neuroendoscopic surgery appears effective for the management of ventriculitis and hydrocephalus after shunt infection. The strategy described in this report might be useful to avoid recurrent shunt infections and malfunctions, simplify a shunt, and reduce the overall duration of hospitalization.39

The preferred method for shunting cerebrospinal fluid in the ventricles is via a ventriculoperitoneal orventriculoatrial shunt. Unfortunately, infection is a major complication of shunt surgery, which placesthe patient at risk of intellectual impairment and death.

Although the most common causative pathogens are Staphylococcus epidermidis and Staphylococcus aureus, gram-negative bacterial infections have increased over the last three decades.

Treatment of Pseudomonas ventriculitis is highly variable, because there are few guidelines for drug selection, administration, and monitoring.

We report a case of post-shunt revision Pseudomonas meningitis/ ventriculitis that was successfully treated by the intraventricular adminstration tobramycin in conjunction with intravenous tobramycin and ceftazidime.40

483 px 0-18 aosRecambio de sistema 286(59.2%)Externalizacin 59 (12.2%)Ext y posterior reemplazo 17 (3.5%)Retiro sin reemplazo 74 (15.3%)

No qx. 64 (13.3%)

El abordaje qx no tuvo relacin con la reinfeccinPromedio 14.8% reinfeccin en 6mMediana de tiempo: 21 das.

ObjectSignificant variation exists in the surgical and medical management of CSF shunt infection.The objectives of this study were to determine CSF shunt reinfection rates following initial CSFshunt infection in a large patient cohort and to determine management, patient, hospital, and surgeonfactors associated with CSF shunt reinfection.MethodsThis retrospective cohort study included children who were in the Pediatric HealthInformation System (PHIS) database, who ranged in age from 0 to 18 years, and who underwentuncomplicated initial CSF shunt placement in addition to treatment for initial CSF shunt infectionbetween January 1, 2001, and December 31, 2008. The outcome was CSF shunt reinfection within6 months. The main predictor variable of interest was surgical approach to treatment of first infection,which was determined for 483 patients. Covariates included patient, hospital, surgeon, and othermanagement factors.ResultsThe PHIS database includes 675 children with initial CSF shunt infection. Surgicalapproach to treatment of the initial CSF shunt infection was determined for 483 children (71.6%).The surgical approach was primarily shunt removal/new shunt placement (in 286 children [59.2%]),but a substantial number underwent externalization (59 children [12.2%]), of whom a subset wenton to have the externalized shunt removed and a new shunt placed (17 children [3.5% overall]). Otherapproaches included nonsurgical management (64 children [13.3%]) and complete shunt removalwithout shunt replacement (74 children [15.3%]).The 6-month reinfection rate was 14.8% (100 of 675 patients). The median time from infection toreinfection was 21 days (interquartile range [IQR] 558 days). Children with reinfection had less time between shunt placement and initial infection (median 50 vs 79 days, p = 0.06). No differencesbetween those with and without reinfection were seen in patient factors (patient age at either shuntplacement or initial infection, sex, race/ethnicity, payer, indication for shunt, number ofcomorbidities, distal shunt location, and number of shunt revisions at first infection); hospital volume;surgeon volume; or other management factors (for example, duration of intravenous antibiotic use).Nonsurgical management was associated with reinfection, and complete shunt removal wasnegatively associated with reinfection. However, reinfection rates did not differ between the 2 mostcommon surgical approaches: shunt removal/new shunt placement (44 [15.4%] of 286; 95% CI11.4%20.1%) and externalization (total 12 [20.3%] of 59; 95% CI 11.0%32.8%). Externalizationfollowed by shunt removal/new shunt placement (5 [29.4%] of 17; 95% CI 10.3%56.0%) andnonsurgical management (15 [23.4%] of 64; 95% CI 13.8%35.7%) had higher, but nonstatisticallysignificant, reinfection rates. The length of stay was shorter for nonsurgical management.ConclusionsSurgical approach to treatment of initial CSF shunt infection was not associatedwith reinfection in this large cohort of patients.41

184 pacientes2 gruposBactiseal: 57% infeccin nosocomial.Cateter simple mas atb sistmica: 51% infeccinNo estadsticamente significativo.

Background In recent years, cranial ventricular catheters impregnated with antimicrobial agents have become available. Theoretically, they provide antibiotic prophylaxis locally without the associated complications of opportunistic nosocomial infections. This study aims to compare antibiotic impregnated catheters with conventional catheters coupled with systemic antibiotics.Methods Patients undergoing emergency neurosurgical operations were recruited. Patients were randomly assigned to antibiotic impregnated catheters (Bactiseal, Codman, Johnson & Johnson, Raynham, MA, USA) or conventional catheters coupled with systemic antibiotics.

Results 184 neurosurgical patients were enrolled between April 2004 and December 2008. Mean duration of ventricular catheter was 10 days for both groups. The proportion of patients with nosocomial infection was not significantly different: 57% (51/90) in the Bactiseal groupand 51% (48/94) in the conventional group (OR 1.3, 0.7 to 2.2). There were also no differences in secondary outcome measures (CSF infection, intensive care unit stay, acute hospital stay and functional outcome) between the two groups.Conclusions Antibiotic impregnated catheters are as effective as systemic antibiotics in the prevention of CSF infection and their corresponding nosocomial infection rates are not significantly different.42

228 pxLos principales factores de riesgo encontrados fueron:La duracin del DVE y El nmero de muestras tomadas.

Background.External ventricular drainage (EVD) is frequently used in neurosurgery for cerebrospinal fluid (CSF) drainage in patients with raised intracranial pressure. The major complication of this procedure is an EVD-related infection, i.e., meningitis or ventriculitis. The purpose of the present retrospective single centre study is to assess the possible causes of these infections.Patients and methods. Two hundred and twenty-eight patients were included in the period from January 1993 until April 2005. Patient and disease demographics, as well as EVD data, and the occurrence of infection were reviewed, compared, and included in a risk-analysis study.

Results. The populations mean age was 56 15 years and the sexes were equally distributed. Most frequently, the indication for EVD was hydrocephalus due to intraventricular haemorrhage (48.2%). An infection was documented in 23.2% of all patients. Duration of EVD drainage appeared to be a risk factor for infection (>11 days: OR 4.1; 95% CI 1.89.2,p= 0.001). CSF sampling frequency was also a significant risk-factor (no sampling: OR 0.2, 95% CI 0.20.5,p= 0.003).

Conclusions. We found a relatively high percentage of EVD-related infections. After multivariate analysis there appears to be a relation with duration of drainage and frequent CSF sampling. As a result, a new EVD protocol is proposed in our institution that we believe will decrease the number of EVD-related infections to a minimum.

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246 DVE en 218 px en 30 meses. Promedio de 7 dias cada DVESe infect el 8.3%Staphylococcus cuag neg 62%Enterococcus sp 19%

External ventricular drainage (EVD) is frequently used in neurosurgery to drain cerebrospinal fluid in patients with raised intracranial pressure.We performed a retrospective single center study in order to evaluate the incidence of EVD-related infections and to identify underlying risk factors.

246 EVDs were placed in 218 patients over a 30-month period. EVD was continued in medianfor 7 days (range 144). The cumulative incidence of EVD-related infections was 8.3% (95% CI, 5.312.7) with a device-associated infection rate of 10.4 per 1000 drainage days (95% CI, 6.216.5).

The pathogens most commonly identified were coagulase-negative Staphylococcus (62%) followed by Enterococcus spp. (19%). Patients with an EVD-related infection had a significantly longer ICU (11 versus 21 days, < 0.01) and hospital stay (20 versus 28.5 days, < 0.01) than patients without. Median total duration of externaldrainage was twice as long in patients with EVD-related infection (6 versus 12 days, < 0.01).

However, there was no significant difference in the duration between first EVD placement and the occurrence of EVD-related infection and EVD removal in patients without EVD-related infection (6 versus 7 days, = 0.87), respectively. Interestingly no risk factor for EVD-related infection couldbe identified in our cohort of patients.44

Purpose The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatricpopulation.Methods In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series.Results One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 015.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17%) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infectionrate was 3.8 % (5/133).

The mean duration of insertion was 10 days (range 042 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone.There was a significant difference (p