Shunt infection treatment [Neurosurgery Wiki]

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====== Shunt infection treatment ======

Management of CSF [[shunt infection]] should include removal of the [[device]], [[external drainage]], parenteral [[antibiotic]]s, and shunt replacement once the CSF is [[sterile]]
((Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, van de Beek D, Bleck TP, Garton HJL, Zunt JR. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017 Mar 15;64(6):e34-e65. doi: 10.1093/cid/ciw861. PMID: 28203777; PMCID: PMC5848239.))
((Whitehead WE, Kestle JR. The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons. Pediatr Neurosurg. 2001;35(4):205-210. doi:10.1159/000050422))
((James HE, Walsh JW, Wilson HD, Connor JD, Bean JR, Tibbs PA. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery. 1980;7(5):459-463. doi:10.1227/00006123-198011000-00006))
((James HE, Walsh JW, Wilson HD, Connor JD. The management of cerebrospinal fluid shunt infections: a clinical experience. Acta Neurochir (Wien). 1981;59(3-4):157-166. doi:10.1007/BF01406345))
((Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J. 2002;21(7):632-636. doi:10.1097/00006454-200207000-00006)).

see also [[Ventriculoperitoneal shunt infection treatment]].
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Current recommendations for the empirical treatment of central nervous system (CNS) infection in the presence of a shunt recommend using IV [[vancomycin]] in combination with an agent that has adequate gram-negative coverage, such as [[cefepime]], [[ceftazidime]], [[cefotaxime]], or [[meropenem]]. The ability of a medication to penetrate the [[CSF]] as well as the activity of the [[antibiotic]] against the bacterial [[biofilm]] are also important to consider for [[antibiotic]] choice
((Yilmaz A, Dalgic N, Musluman M, et al. Linezolid treatment of shunt-related cerebrospinal fluid infections in children. J Neurosurg Pediatr. 2010;5:443-448.)).

Such agents should be administered until the pathogen is identified and definitive treatment determined
((Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267-1284.))
((Van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med. 2010;362:146-154.)).

For patients refractory to [[vancomycin]] therapy, [[linezolid]] 10 mg/kg every 8 hours has been shown to be effective as monotherapy in pediatric patients
((Yilmaz A, Dalgic N, Musluman M, et al. Linezolid treatment of shunt-related cerebrospinal fluid infections in children. J Neurosurg Pediatr. 2010;5:443-448.)).

The addition of [[rifampin]] as adjunctive therapy may also be considered due to its penetration into the CNS
((Hedberg A, Hardemark HG, Olsson-Liljequist B, et al. Penetration of fusidic acid and rifampicin into cerebrospinal fluid in low grade inflammatory meningitis caused by Staphylococcus epidermidis. Clin Microbiol Infect. 2004;10:765-768.)).

 The length of antibiotic therapy depends largely on the surgical approach used, the type of shunt, and the pathogen involved, with one study reporting a duration of therapy range of 4 to 47 days
((Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32.))
((Simon TD, Hall M, Dean JM, et al. Reinfection following initial cerebrospinal fluid shunt infection. J Neurosurg Pediatr. 2010;6:277-285.)).

More specifically, 7 to 10 days has been suggested for treatment duration
((Van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med. 2010;362:146-154.))
with a longer course (10-14 days) recommended for gram-negative infections
((Wells DL, Allen JM. Ventriculoperitoneal shunt infections in adult patients. AACN Adv Crit Care. 2013;24:6-12.)).

In the case of complicated or treatment-resistant shunt infections, clinicians should consider intrathecal or intraventricular administration of antibiotics for increased efficacy due to their ability to achieve higher bactericidal concentrations within the CNS
((Van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med. 2010;362:146-154.)).

Vancomycin and gentamicin are commonly used in this situation; however, there are no definitive recommendations on their use
((Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267-1284.))
((Van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med. 2010;362:146-154.))
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It is important that empirical antibiotic therapy for management is guided by accurate knowledge of prevailing aetiologies and local antibiotic sensitivity patterns.

===== Intraventricular antibiotic =====
see [[Intraventricular antibiotic]]

===== Removal of shunt hardware =====

In [[2017]], the Infectious Diseases Society of America (IDSA) published guidelines for healthcare-associated [[ventriculitis treatment]] and [[meningitis treatment]]
((Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017;64(6):e34-e65. doi:10.1093/cid/ciw861)).

The removal of the infected [[hardware]], placement of an [[external ventricular drain]], [[culture]]s, and treatment with IV or [[intraventricular antibiotic]]s are all shown to be part of an effective management process
((Wells DL, Allen JM. Ventriculoperitoneal shunt infections in adult patients. AACN Adv Crit Care. 2013;24:6-12.)).

Optimal management of CSF shunt infection should include complete removal of the device, external drainage, and subsequent shunt replacement once CSF is sterile
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In most instances, during the initial treatment with [[antibiotic]]s the [[shunt]] is either externalized (i.e., tubing is diverted at some point distal to the [[ventricular catheter]] and connected to a closed drainage system), or sometimes the entire [[shunt]] may be removed. In the latter case, some means of CSF [[drainage]] must be provided in [[shunt-dependent hydrocephalus]] cases, either by insertion of an [[external ventricular drain]] (EVD), or by intermittent ventricular [[tap]]s (rarely employed) or LPs (with communicating HCP). [[EVD]] allows easy monitoring of CSF [[flow]], control of [[ICP]], and repeated sampling for signs of resolution of infection (normalization of WBC count and surveillance cultures). In addition, EVD allows for possible administration of [[intrathecal]] [[antibiotic]]s. In symptomatic patients or those with a positive CSF culture
((Steinbok P, Cochrane DD, Kestle JRW. The Significance of Bacteriologically Positive Ventriculoperitoneal Shunt Components in the Absence of Other Signs of Shunt Infection. J Neurosurg. 1996; 84:617–623)), 
any [[hardware]] removed should be cultured, as only ≈ 8% are sterile in [[shunt infection]]s. [[Skin]] organisms are fastidious and may take several days to grow.
If there is an [[abdominal pseudocyst]], the fluid should be drained through the [[peritoneal catheter]] before removing it.