Zero Tolerance

87

PAPER

Zero tolerance to shunt infections: can it be achieved?
M S Choksey, I A Malik
............................................................................................................................... See end of article for authors’ affiliations ....................... Correspondence to: Mr M S Choksey, Department of Neurosurgery, University Hospitals Coventry &Warwickshire NHS Trust, Walsgrave Hospital, Bridge Road, Coventry CV2 2DX, UK; munchi.choksey@ wh-tr.wmids.nhs.uk Received 5 November 2002 Revised accepted 1 May 2003 ....................... J Neurol Neurosurg Psychiatry 2004;75:87–91

Objective : To evaluate the rigid application of a technique of shunt placement aimed at the eradication of postoperative shunt infection in neurosurgical practice. Method:All shunt procedures were performed or closely supervised by the senior author (MSC). The essentials were the use of intravenous peri- and postoperative antimicrobials, rigid adherence to classical aseptic technique, liberal use of topical antiseptic (BetadineH), and avoidance of haematomas. Results: Of 176 operations, 93 were primary procedures; 33 patients underwent revisions, some multiple.Only one infection occurred, seven months postoperatively, secondary to appendicitis with peritonitis. The infecting Streptococcus faecalis appeared to ascend from the abdominal cavity. Conclusion: A rigidly applied protocol and strict adherence to sterile technique can reduce shunt infections to a very low level.

nfection remains a serious complication of shunt implantation, with a mortality rateranging from 1.5–22%.1 2 Those who survive risk intellectual, cognitive, and neurological deficits.3 Infection has been reported to occur in 5–15% of shunt procedures.4–6 However, some authors have described lower infection rates ranging from 0.3– 5%.7–12 Many factors have been associated with shunt infection, including the age of the patient,1 13–15 the aetiology of hydrocephalus,1 and the typeof shunt implanted.16 17 Most studies of the use of prophylactic antibiotic medications have given inconclusive results,2 7 15 18–24 and there has been no definite evidence that prophylactic antimicrobial medications reduce shunt infection rates. Other factors such as timing of the operation (elective/emergency), duration of surgery, number of operations/patient, number of people in the operationroom, and length of time during which the shunt material is exposed to the atmosphere have been highlighted as contributing to shunt infection; these may all be included in specific ‘‘theatre discipline’’. In January 1994, the senior author (MSC) established a strict protocol for shunt placement with vigorous attention to asepsis, antisepsis, and perioperative antimicrobial therapy. We report theresults of 176 shunt procedures in 126 patients over a period of seven and a half years.

I

METHODS
Between January 1994 and mid-July (15th) 2001, 126 patients underwent shunt insertions and revision procedures in the Department of Neurosurgery at University Hospitals Coventry & Warwickshire NHS Trust, Walsgrave. A total of 176 shunt procedures were performed in 126 patients withhydrocephalus. Although the majority of procedures involved ventriculoperitoneal shunts, a variety of other shunts were also inserted, including lumboperitoneal, cystoperitoneal, ventriculopleural, syringopleural, and ventriculoatrial shunts. Primary shunt procedures had been performed previously at other centres in 33 patients; these patients underwent shunt revision for various reasons, and have beenincluded in this study. All shunt material removed during revision was sent for bacteriological analysis.

Operative technique All operations were carried out in a dedicated neurosurgical operating theatre, which was seldom, if ever, used for general surgical cases. The operating theatre personnel were all neurosurgically trained. Most operations were carried out by single surgeons. All operating...