Chapter 11 : Infections of Central Nervous System Shunts

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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
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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
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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
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1. Ajir, F.,, A. B. Levin,, and T. A. Duff. 1981. Effect of prophylactic methicillin on cerebrospinal fluid shunt infections in children. Neurosurgery 9: 6 8.
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: 66 68.
3. Ammirati, M.,, and A. J. Raimondi. 1987. Cerebrospinal fluid shunt infections in children. Child. Nervous Syst. 3: 106 109.
4. Arroyo, J. C.,, and E. A. Quindlen. 1993. Accumulation of vancomycin after intraventricular infusions. South. Med. J. 76: 1554 1555.
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: 369 376.
6. Bayston, R. 1975. Antibiotic prophylaxis in shunt surgery. Dev. Med. Child Neurol. 17( Suppl. 35): 99 l03.
7. Bayston, R.,, C. Compton,, and K. Richards. 1994. Production of extracellular slime by coryneforms colonizing hydrocephalus shunts. J. Clin. Microbiol. 32: 1705 1709.
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: 25 28.
9. Blomstedt, G. C. 1985. Results of trimethoprim-sulfamethoxazole prophylaxis in ventriculostomy and shunting procedures: a double-blind randomized trial. J. Neumsurg. 62: 694 697.
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: 417 423.
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: 860 863.
12. Choux, M.,, L. Genitori,, D. Lang,, and G. Lena. 1992. Shunt implantation: reducing the incidence of shunt infection. J. Neurosurg. 77: 875 880.
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: 555 560.
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: 21 28.
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: 467 475.
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: 37 40.
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: 389 394.
18. Fossieck, B., Jr.,, and R. H. Parker. 1974. Neurotoxicity during intravenous infusion of penicillin: a review. J. Clin. Pharmacol. 14: 504 512.
19. Frame, P. T.,, and R. L. McLaurin. 1984. Treatment of CSF shunt infections with intrashunt plus oral antibiotic therapy. J. Neurosurg. 60: 354 360.
20. George, R.,, L. Leibrock,, and M. Epstein. 1979. Long-term analysis of cerebrospinal fluid shunt infections: a 25 year experience. J. Neurosurg. 51: 804 811.
21. Gerner-Sniidt, P.,, E. Stenager,, C. Kock-.Jensen. 1988. Treatment of ventriculostomy-related infections. Acta Neurochir. (Wein) 91: 47 49.
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: 633 636.
23. Guevara, J. A.,, G. Zuccaro,, B. S. Trevisan,, and C. D. Denoya. 1987. Bacterial adhesion to cerebrospinal fluid shunts. J. Neurosurg. 67: 438 445.
24. Haines, S. J. 1986. Antibiotic prohylaxis in neurosurgery. Clin. Neurosurg. 33: 633 642.
25. Haines, S. J. 1989. Efficacy of antibiotic prophylaxis in clean neurosurgical operations. Neurosurgery 24: 401 405.
26. Haines, S. J.,, and B. C. Walters. 1994. Antibiotic prophylaxis for cerebrospinal fluid shunts: a metaanalysis. Neurosurgery 34: 87 92.
27. Hanekom, W. A.,, and R. Yogev. 1996. Cerebrospinal fluid shunt infections. Adv. Pedialr. Infect. Dis. 11: 29 54.
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: 148 155.
29. Ignelzi, R. J.,, and W. M. Kirsch. 1975. Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J. Neurosurg. 42: 679 682.
30. James, H. E., 1981. Infections associated with cerebrospinal fluid prosthetic devices, p. 23 41. 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: 75 77.
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: 459 463.
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: 50 54.
34. Jones, R. F.,, W. A. Stening,, B. C. Kwok,, and T. M. Sands. 1993. Third ventriculostomy for shunt infections in children. Neurosurgery 32: 855 859.
35. Kelly, P. J. 1991. Stereotactic third ventriculostomy in patients with non-tumoural adolescent/adult onset aqueduct stenosis and symptomatic hydrocephalus. J. Neurosurg. 75: 865 873.
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: 163 165.
37. Keucher, T. R.,, and J. Mealey, Jr. 1979. Long-term results after ventriculoatrial and ventriculoperitoneal shunting for infantile hydrocephalus. J. Neurosurg. 50: 179 186.
38. Kloos, W. E.,, and K. H. Schleifer. 1975. Simplified scheme for routine identification of human Staphylococcus species. J. Clin. Microbiol. 1: 82 88.
39. Kontny, U.,, B. Hotting,, and P. Gutjahr. 1993. CSF shunt infections in children. Infection 21: 89 92.
40. Lambert, M.,, A. E. MacKinnon,, and A. Vaislinav. 1984. Comparison of two methods of prophylaxis against CSF shunt infection. Z. Kinderelur. 39: 109 110.
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: 98 103.
42. Luthardt, T. 1970. Bacterial infections in ventriculo-auricular shunt systems. Dev. Med. Child Neurol. 12( Suppl. 22): 105 109.
43. Malis, L. I. 1979. Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 5: 339 343.
44. Mates, S.,, J. Glaser,, and K. Shapiro. 1982. Treatment of cerebrospinal fluid shunt infections with medical therapy alone. Neurosurgery 11: 781 783.
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: 553 559.
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: 182 189.
47. McLaurin, R. L.,, and P. T. Frame. 1987. Treatment of infections of cerebrospinal fluid shunts. Rev. Infect. Dis. 9: 595 603.
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: 338 342.
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: 118 122.
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): 85 90.
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): 110 113.
52. North, B.,, P. Reilly. 1986. Comparison among three methods of intracranial pressure recording. Neurosurgery 18: 730 732.
53. Odio, C.,, G. H. McCracken,, and J. D. Nelson. 1984. CSF shunt infections in pediatrics. Am. J. Dis. Child 138: 1103 1108.
54. Perrin, , J. C. S.,, and R. L. McLaurin. 1967. Infected ventriculoatrial shunts: a method of treatment. J. Neurosurg. 27: 21 26.
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: 223 242.
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: 1142 1143.
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: 1072 1078.
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: 935 938.
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: 317 319.
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: 267 273.
61. Salmon, J. H. 1972. Adult hydrocephalus: evaluation of shunt therapy in 80 patients. J. Neurosurg. 37: 423 428.
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: 695 701.
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: 264 270.
64. Schoenbaum, S. C.,, P. Gardner,, and J. Shillito. 1975. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations, and therapy. J. Infect. Dis. 131: 543 552.
65. Sells, C. J.,, D. B. Shurtleff,, and J. D. Loeser. 1977. Gram-negative cerebrospinal fluid shunt-associated infections. Pediatrics 59: 613 618.
66. Shapiro, S.,, J. Boaz,, M. Kleinan,, J. Kalshek,, and J. Mcaley. 1988. Origin of organisms infecting ventricular shunts. Neurosurgery 22: 868 872.
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: 55 62.
68. Siegal, T.,, R. Pfeffer,, I. Steiner. 1988. Antibiotic therapy for infected Ommaya reservoir systems. Neurosurgery 22: 97 100.
69. Smith, K. A. 1987. Head trauma: comparison of infection rates for different methods of intracranial pressure monitoring. J. Neurosurg. 19: 310 314.
70. Stamos, J. K.,, B. A. Kaufman,, and R. Yogev. 1993. Ventriculoperitoneal shunt infections with gram-negative bacteria. Neurosurgery 33: 858 862.
71. Tung, H.,, C. Raffel,. and J. G. McComb. 1991. Ventricular cerebrospinal fluid eosinophilia in children with ventriculoperitoneal shunts. . J. Neurosurg. 75: 541 544.
72. Venes, J. L. 1976. Control of shunt infection: report of 150 consecutive cases. . J. Neurosurg. 45: 311 314.
73. Vernet, O.,, R. Campiche,. and N. de Tribolet. 1993. Long-term results after ventriculoatrial shunting in children. Child. Nerv. Sysi. 9: 253 255.
74. Wald, S. L.,, and R. L. McLaurin. 1980. Cerebrospinal fluid antibiotic levels during treatment of shunt infections. . J. Neurosurg. 52: 41 46.
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: 1014 1021.
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: 1174 1177.
77. Watanabe, I.,, G. R. Hodges,, and D. L. Dworzack. 1978. Neurotoxicity of intrathecal gentamicin: a case report and experimental study. Aim. Neurol. 4: 564 572.
78. Yogev, R. 1985. Cerebrospinal fluid shunt infections: a personal view. Pedialr. Infect. Pis. J. 4: 113 118.
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: 548 554.
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: 212 213.
81. Yu, H. C.,, and R. H. Patterson, Jr. 1973. Prophylactic antimicrobial agents after ventriculoatriostomy for hydrocephalus. J. Pedialr. Surg. 8: 881 884.


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

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