Shunt infection treatment
Management of CSF shunt infection should include removal of the device, external drainage, parenteral antibiotics, and shunt replacement once the CSF is sterile 1) 2) 3) 4) 5).
see also Ventriculoperitoneal shunt infection treatment.
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 6).
Such agents should be administered until the pathogen is identified and definitive treatment determined 7) 8).
For patients refractory to vancomycin therapy, linezolid 10 mg/kg every 8 hours has been shown to be effective as monotherapy in pediatric patients 9).
The addition of rifampin as adjunctive therapy may also be considered due to its penetration into the CNS 10).
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 11) 12).
More specifically, 7 to 10 days has been suggested for treatment duration 13) with a longer course (10-14 days) recommended for gram-negative infections 14).
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 15).
Vancomycin and gentamicin are commonly used in this situation; however, there are no definitive recommendations on their use 16) 17)
It is important that empirical antibiotic therapy for management is guided by accurate knowledge of prevailing aetiologies and local antibiotic sensitivity patterns.
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 18).
The removal of the infected hardware, placement of an external ventricular drain, cultures, and treatment with IV or intraventricular antibiotics are all shown to be part of an effective management process 19).
Optimal management of CSF shunt infection should include complete removal of the device, external drainage, and subsequent shunt replacement once CSF is sterile
In most instances, during the initial treatment with antibiotics 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 taps (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 antibiotics. In symptomatic patients or those with a positive CSF culture 20), any hardware removed should be cultured, as only ≈ 8% are sterile in shunt infections. 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.