Chapter 11 : Infections of Central Nervous System Shunts

MyBook is a cheap paperback edition of the original book and will be sold at uniform, low price.

Preview this chapter:
Zoom in

Infections of Central Nervous System Shunts, Page 1 of 2

| /docserver/preview/fulltext/10.1128/9781555818067/9781555811778_Chap11-1.gif /docserver/preview/fulltext/10.1128/9781555818067/9781555811778_Chap11-2.gif


Cerebrospinal fluid (CSF) shunt infections may lead to ventriculitis, ventricular compartmentalization, and cortical mantle thinning, as well as meningitis, subdural empyema, and seizures. In addition, shunt infections have been shown to increase mental retardation and deterioration of mental capacity. The manifestations of central nervous system (CNS) shunt infections are variable. The most common presentation is a nonspecific one consisting of mild fever, nausea, vomiting, malaise, or signs of increased intracranial pressure (ICP) such as headache or altered consciousness. A unique complication of patients with ventriculovascular shunts is the development of shunt nephritis, a form of acute glomerulonephritis. In the majority of these cases the infecting organism has been , but other bacteria such as corynebacteria can cause this complication. The choice of antimicrobial therapy must be individualized, depending upon the clinical appearance of the patient, cerebrospinal fluid findings, and local patterns of antimicrobial susceptibility. A wide variety of choices is available for treatment of gram-negative shunt infections. A number of expanded-spectrum cephalosporins (e.g. cefotaxime, ceftriaxone, and ceftazidime) achieve therapeutic concentrations in the cerebrospinal fluid (CSF) and ventricular fluid after intravenous administration in patients with inflamed meninges. Some experts prefer to treat CNS shunt infections with both systemic and intraventricular antibiotics because of patient-to-patient variability in antibiotic concentrations achieved in ventricular fluid after intravenous therapy alone.

Citation: Yogev R, Bisno A. 2000. Infections of Central Nervous System Shunts, p 231-246. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch11
Highlighted Text: Show | Hide
Loading full text...

Full text loading...


Image of Figure 1
Figure 1

Commonly used CSF shunting system. The proximal portion ( ) is inserted into one of the cerebral ventricles. The reservoir( ) allows an easy access for CSF fluid sampling, and patency testing and the pressure-regulating valve ( )regulate the CSF flow. The distal catheter can be inserted into various body cavities (e.g., the peritoneal cavity in the VP shunt, the pleural cavity in the ventriculopleural shunt, or the vena cava in the VA shunt).

Citation: Yogev R, Bisno A. 2000. Infections of Central Nervous System Shunts, p 231-246. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint
Image of Figure 2
Figure 2

Peritoneal cyst in an 11-month-old hydrocephalic infant with a malfunction of a VP shunt. The X ray shows the distal tip of the shunt catheter coiled in the left lower quadrant of the abdomen. The sonogram (inset) demonstrates that the catheter is contained within an echo-free cystic mass. (Courtesy of Thomas F. Boulden, LeBonheur Children's Medical Center, Memphis, Tenn.)

Citation: Yogev R, Bisno A. 2000. Infections of Central Nervous System Shunts, p 231-246. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch11
Permissions and Reprints Request Permissions
Download as Powerpoint


1. Ajir, F.,, A. B. Levin,, and T. A. Duff. 1981. Effect of prophylactic methicillin on cerebrospinal fluid shunt infections in children. Neurosurgery 9:68.
2. Alvarez-Garijo, J. A.,, M. V. Mengual. 1982. Infection rate with and without prophylactic antibiotic therapy after shunt insertion for hydrocephalus. Monogr. Neural Sci. 8:6668.
3. Ammirati, M.,, and A. J. Raimondi. 1987. Cerebrospinal fluid shunt infections in children. Child. Nervous Syst. 3:106109.
4. Arroyo, J. C.,, and E. A. Quindlen. 1993. Accumulation of vancomycin after intraventricular infusions. South. Med. J. 76:15541555.
5. Aucoin, P. J.,, H. R. Kotilainen,, N. M. Ganlz,, R. Davidson,, P. Kellog,, and B. Stone. 1986. Intracranial pressure monitors: epidemiologic study of risk factors and infections. Am. J. Med. 80:369376.
6. Bayston, R. 1975. Antibiotic prophylaxis in shunt surgery. Dev. Med. Child Neurol. 17(Suppl. 35):99l03.
7. Bayston, R.,, C. Compton,, and K. Richards. 1994. Production of extracellular slime by coryneforms colonizing hydrocephalus shunts. J. Clin. Microbiol. 32:17051709.
8. Bayston, R.,, and S. R. Penny. 1972. Excessive production of mucoid substance in Staphylococcus SUA: a possible factor in colonization of I loiter shunts. Dev. Med. Child Neurol. 14(Suppl. 271:2528.
9. Blomstedt, G. C. 1985. Results of trimethoprim-sulfamethoxazole prophylaxis in ventriculostomy and shunting procedures: a double-blind randomized trial. J. Neumsurg. 62:694697.
10. Bolton, W. K.,, M. A. Sande,, D. E. Normansell,, B. C. Sturgill,, and F. B. Westervelt, Jr. 1975. Ventriculojugular shunt nephritis with Corynebacterium bovi.s. Am. J. Med. 59:417423.
11. Callaghan, R. P.,, S. J. Cohen,, and G. T. Stewart. 1961. Septicaemia due to colonization of Spitz-Holter valves by staphylococci: five cases treated with methicillin. Br. Med. J. 1:860863.
12. Choux, M.,, L. Genitori,, D. Lang,, and G. Lena. 1992. Shunt implantation: reducing the incidence of shunt infection. J. Neurosurg. 77:875880.
13. Diaz-Mitoma, F.,, G. K. M. Hardin,, D. J. Hoban,, R. S. Roberts,, and D. E. Low. 1987. Clinical significance of a test for slime production in ventriculoperitoneal shunt infections caused by coagulase-negative staphylococci. J. Infect. Dis. 156:555560.
14. Erashin, Y.,, D. G. McLonc,, B. B. Storrs,, and R. Yogev. 1989. Review of 3,017 procedures for the management of hydrocephalus in children. Concepts Pedialr. Neurosurg. 9:2128.
15. Etienne, J.,, B. Charpin,, J. Grando,, Y. Brun,, M. Bes,, and J. Fleurette. 1991. Characterization of clinically significant isolates of Staphylococcus epidermidis from patients with cerebrospinal fluid shunt infections. Epidemiol. Inject. 106:467475.
16. Farber, B. F.,, M. H. Kaplan,, and A. G. Clogston. 1988. Staphylococcus epidermidis extracted slime inhibits the antimicrobial action of glycopeptide antibiotics. J. Infect. Dis. 161:3740.
17. Forward, K. R.,, H. D. Fewer,, and H. G. Stiver. 1983. Cerebrospinal fluid shunt infections: a review of 35 infections in 32 patients. .J. Nettrosurg. 59:389394.
18. Fossieck, B., Jr.,, and R. H. Parker. 1974. Neurotoxicity during intravenous infusion of penicillin: a review. J. Clin. Pharmacol. 14:504512.
19. Frame, P. T.,, and R. L. McLaurin. 1984. Treatment of CSF shunt infections with intrashunt plus oral antibiotic therapy. J. Neurosurg. 60:354360.
20. George, R.,, L. Leibrock,, and M. Epstein. 1979. Long-term analysis of cerebrospinal fluid shunt infections: a 25 year experience. J. Neurosurg. 51:804811.
21. Gerner-Sniidt, P.,, E. Stenager,, C. Kock-.Jensen. 1988. Treatment of ventriculostomy-related infections. Acta Neurochir. (Wein) 91:4749.
22. Gombert, M. E.,, S. H. Landesman,, M. L. Corrado,, S. C. Stein,, E. T. Melvin,, and M. Cummings. 1981. Vancomycin and rifampin therapy for Staphylococcus epidermidis meningitis associated with CFS shunts. J. Neurosurg. 55:633636.
23. Guevara, J. A.,, G. Zuccaro,, B. S. Trevisan,, and C. D. Denoya. 1987. Bacterial adhesion to cerebrospinal fluid shunts. J. Neurosurg. 67:438445.
24. Haines, S. J. 1986. Antibiotic prohylaxis in neurosurgery. Clin. Neurosurg. 33:633642.
25. Haines, S. J. 1989. Efficacy of antibiotic prophylaxis in clean neurosurgical operations. Neurosurgery 24: 401405.
26. Haines, S. J.,, and B. C. Walters. 1994. Antibiotic prophylaxis for cerebrospinal fluid shunts: a metaanalysis. Neurosurgery 34:8792.
27. Hanekom, W. A.,, and R. Yogev. 1996. Cerebrospinal fluid shunt infections. Adv. Pedialr. Infect. Dis. 11: 2954.
28. Hodges, G. R.,, I. VVatanabe,, P. Singer,, S. Rengachary,, D. Reeves,, D. R. Jusetesen,, S. E. Worley,, and E. P. Gephardt, Jr. 1981. Central nervous system toxicity of intraventricularly administered gentamicin in adult rabbits. J. Infect. Dis. 143:148155.
29. Ignelzi, R. J.,, and W. M. Kirsch. 1975. Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J. Neurosurg. 42:679682.
30. James, H. E., 1981. Infections associated with cerebrospinal fluid prosthetic devices, p. 2341. In B. Sugarnian, and E. J. Young (ed.) Infections Associated with Prosthetic Devices. CRC Press. Inc., Boca Raton, Fla.
31. James, H. E.,, J. W. Walsh,, H. D. Wilson,, and J. D. Connor. 1982. Management of cerebrospinal fluid shunt infections: a clinical experience. Monogr. Neural Sci. 8:7577.
32. James, H. E.,, J. W. Walsh,, H. D. Wilson,, J. D. Connor,, J. R. Beun,, and P. A. Tibbs. 1980. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery 7:459463.
33. James, H. E.,, H. D. Wilson,, J. D. Connor,, and J. W. Walsh. 1982. Intraventricular cerebrospinal fluid antibiotic concentrations in patients with intraventricular infections. Neurosurgery 10:5054.
34. Jones, R. F.,, W. A. Stening,, B. C. Kwok,, and T. M. Sands. 1993. Third ventriculostomy for shunt infections in children. Neurosurgery 32:855859.
35. Kelly, P. J. 1991. Stereotactic third ventriculostomy in patients with non-tumoural adolescent/adult onset aqueduct stenosis and symptomatic hydrocephalus. J. Neurosurg. 75:865873.
36. Kestle, J. R.,, H. J. Hoffman,, D. Soloniuk,, R. P. Humphreys,, J. M. Drak,, and E. B. Hendrick. 1993. A concerted effort to prevent shunt infection. Child. Nerv. Syst. 9:163165.
37. Keucher, T. R.,, and J. Mealey, Jr. 1979. Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J. Neurosurg. 50:179186.
38. Kloos, W. E.,, and K. H. Schleifer. 1975. Simplified scheme for routine identification of human Staphylococcus species. J. Clin. Microbiol. 1:8288.
39. Kontny, U.,, B. Hotting,, and P. Gutjahr. 1993. CSF shunt infections in children. Infection 21:8992.
40. Lambert, M.,, A. E. MacKinnon,, and A. Vaislinav. 1984. Comparison of two methods of prophylaxis against CSF shunt infection. Z. Kinderelur. 39:109110.
41. Langley, J. M.,, J. C. LeBlanc,, and J. Drake. 1993. Efficacy of antimicrobial prophylaxis in placement of cerebrospinal fluid shunts: meta-analysis. Clin. Infect. Dis. 17:98103.
42. Luthardt, T. 1970. Bacterial infections in ventriculo-auricular shunt systems. Dev. Med. Child Neurol. 12(Suppl. 22):105109.
43. Malis, L. I. 1979. Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 5: 339343.
44. Mates, S.,, J. Glaser,, and K. Shapiro. 1982. Treatment of cerebrospinal fluid shunt infections with medical therapy alone. Neurosurgery 11:781783.
45. Mayhall, C. G.,, N. H. Archer,, V. A. Lamb,, A. C. Spadora,, J. W. Baggett,, J. D. Ward,, and R. K. Narayan. 1984. Ventriculostomy-related infections. A prospective epidemiologic study. N. Engl. J. Med 310:553559.
46. McCullough, D. C.,, J. G. Kane,, J. H. Presper,, and M. Wells. 1980. Antibiotic prophylaxis in ventricular shunt surgery. I. Reduction of operative infection rales with methicillin. Child. Brain 7:182189.
47. McLaurin, R. L.,, and P. T. Frame. 1987. Treatment of infections of cerebrospinal fluid shunts. Rev. Infect. Dis. 9:595603.
48. McLone, D. G.,, D. Czyzewski,, A. J. Raimondi,, and R. C. Sommers. 1982. Central nervous system infections as a limiting factor in the intelligence of children with myelomeningocoele. Pediatrics 70:338342.
49. Morissette, I.,, M. Gourdeau,, and J. Francoeur. 1993. CSF shunt infections: a fifteen-year experience with emphasis on management and outcome. Can. J. Neurol. Sci. 20:118122.
50. Morrice, J. J.,, and D. G. Young. 1974. Bacterial colonization of Holler valves: a ten-year survey. Dev. Med. Child Neurol. 16(Suppl. 32):8590.
51. Nicholas, J. L.,, I. M. Kamal,, and H. B. Eckstein. 1970. Immediate shunt replacement in the treatment of bacterial colonization of Holler valves. Dev. Med. Child Neurol. 12(Suppl. 22):110113.
52. North, B.,, P. Reilly. 1986. Comparison among three methods of intracranial pressure recording. Neurosurgery 18:730732.
53. Odio, C.,, G. H. McCracken,, and J. D. Nelson. 1984. CSF shunt infections in pediatrics. Am. J. Dis. Child 138:11031108.
54. Perrin, , J. C. S.,, and R. L. McLaurin. 1967. Infected ventriculoatrial shunts: a method of treatment. J. Neurosurg. 27:2126.
55. Piatt, J. H., Jr.,, and C. V. Carlson. 1993. A search for determinants of cerebrospinal fluid shunt survival: retrospective analysis of a 14-year institutional experience. Pediatr. Neurosurg. 19:223242.
56. Reesor, C.,, A. W. Chow,, A. Kureishi,, and P. J. Jewesson. 1988. Kinetics of intraventricular vancomycin in infections of cerebrospinal fluid shunts. J. Infect. Dis. 158:11421143.
57. Renier, D.,, J. Lacombe,, A. Pierre-Kahn,, C. Sainte-Rosc,, and J. F. Hirsch. 1984. Factors causing acute shunt infection—computer analysis of 1,174 operations. J. Neurosurg. 61:10721078.
58. Rieder, M. J.,, T. C. Frewen,, and R. F. Del Maestro. 1987. The effect of cephalothin prophylaxis on postoperative ventriculoperitoneal shunt infections. Can. Med. Assoc. J. 136:935938.
59. Ring, J. C.,, K. L. Cates,, K. K. Belani,, T. L. Gaston,, R. J. Sveum,, and S. C. Marker. 1979. Rifampin for CSF shunt infections caused by coagulase-negative staphylococci. J. Pediatr. 95:317319.
60. Roitberg, B. Z.,, T. Tomita,, and D. G. McLone. 1998. Abdominal cerebrospinal fluid pseudocyst: a complication of ventriculoperitoneal shunt in children. Pediatr. Neurosurg. 29:267273.
61. Salmon, J. H. 1972. Adult hydrocephalus: evaluation of shunt therapy in 80 patients. J. Neurosurg. 37: 423428.
62. Samtleben, W.,, G. Bauriedel,, T. Bosch,, C. Goetz,, B. Klare,, and H. J. Gurland. 1993. Renal complications of infected ventriculoatrial shunts. An if. Org. 17:695701.
63. Schimke, R. T.,, P. H. Black,, V. H. Mark,, and M. N. Swartz. 1961. Indolent Staphylococcus albas or aureus bacteremia after venlriculoatristomy: role of foreign body in its initiation and perpetuation. N. Engl. J. Med. 264:264270.
64. Schoenbaum, S. C.,, P. Gardner,, and J. Shillito. 1975. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J. Infect. Dis. 131:543552.
65. Sells, C. J.,, D. B. Shurtleff,, and J. D. Loeser. 1977. Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics 59:613618.
66. Shapiro, S.,, J. Boaz,, M. Kleinan,, J. Kalshek,, and J. Mcaley. 1988. Origin of organisms infecting ventricular shunts. Neurosurgery 22:868872.
67. Shurtleff, D. B.,, E. L. Foltz,, R. D. Weeks,, and J. Loeser. 1974. Therapy of Staphylococcus epidermidis: infections associated with cerebrospinal fluid shunts. Pediatrics 53:5562.
68. Siegal, T.,, R. Pfeffer,, I. Steiner. 1988. Antibiotic therapy for infected Ommaya reservoir systems. Neurosurgery 22:97100.
69. Smith, K. A. 1987. Head trauma: comparison of infection rates for different methods of intracranial pressure monitoring. J. Neurosurg. 19:310314.
70. Stamos, J. K.,, B. A. Kaufman,, and R. Yogev. 1993. Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33:858862.
71. Tung, H.,, C. Raffel,. and J. G. McComb. 1991. Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts. .J. Neurosurg. 75:541544.
72. Venes, J. L. 1976. Control of shunt infection: report of 150 consecutive cases. .J. Neurosurg. 45:311314.
73. Vernet, O.,, R. Campiche,. and N. de Tribolet. 1993. Long-term results after ventriculoatrial shunting in children. Child. Nerv. Sysi. 9:253255.
74. Wald, S. L.,, and R. L. McLaurin. 1980. Cerebrospinal fluid antibiotic levels during treatment of shunt infections. .J. Neurosurg. 52:4146.
75. Walters, B. C.,, H. J. Hoffman,, E. B. Hendrick,, and R. P. Humphreys. 1984. Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J. Neurosurg. 60:10141021.
76. Wang, E. E. L.,, C. G. Prober,, B. E. Hendrick,, H. J. Hoffman,, and R. P. Humphreys. 1984. Prophylactic sulfamethoxazole and trimethoprim in ventriculoperitoneal shunt surgery: a double-blind, randomized, placebo-controlled trial. JAMA 251:11741177.
77. Watanabe, I.,, G. R. Hodges,, and D. L. Dworzack. 1978. Neurotoxicity of intrathecal gentamicin: a case report and experimental study. Aim. Neurol. 4:564572.
78. Yogev, R. 1985. Cerebrospinal fluid shunt infections: a personal view. Pedialr. Infect. Pis. J. 4:113118.
79. Younger, J. J.,, G. D. Christensen,, D. L. Bartley,, J. C. H. Simmons,, and F. F. Barrett. 1987. Coagulase-negative staphylococci isolated from cerebrospinal fluid shunts: importance of slime production, species identification, and shunt removal to clinical outcome. J. Infect. Dis. 156:548554.
80. Younger, J. J.,, J. C. H. Simmons,, and F. F. Barrett. 1987. Failure of single-dose intraventricular vancomycin for cerebrospinal fluid shunt surgery prophylaxis. Pedialr. Infect. Dis. J. 6:212213.
81. Yu, H. C.,, and R. H. Patterson, Jr. 1973. Prophylactic antimicrobial agents after ventriculoatriostomy for hydrocephalus. J. Pedialr. Surg. 8:881884.


Generic image for table
Table 1

Shunt infection cure rates with various therapeutic modalities

Citation: Yogev R, Bisno A. 2000. Infections of Central Nervous System Shunts, p 231-246. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch11
Generic image for table
Table 2

Duration of antibiotic therapy for patients with shunt infections

Citation: Yogev R, Bisno A. 2000. Infections of Central Nervous System Shunts, p 231-246. In Waldvogel F, Bisno A (ed), Infections Associated with Indwelling Medical Devices, Third Edition. ASM Press, Washington, DC. doi: 10.1128/9781555818067.ch11

This is a required field
Please enter a valid email address
Please check the format of the address you have entered.
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error