gms | German Medical Science

Objective: Surgical and antibiotic treatment for VP/VA shunt infections is controversial. We have analyzed the treatment of 87 shunt infections in 74 patients at our institution from 2002 to 2008.

Methods: Treatment followed an institutional guideline. A shunt infection was diagnosed if two of the following criteria were met: clinical signs, CSF pleocytosis, positive CSF/shunt hardware cultures. Treatment consisted of shunt removal (and placement of an EVD if necessary) and primary antibiotic therapy with cefuroxim/flucloxacillin (unless concomitant diseases required a different choice) followed by an antibiotic treatment regimen based on CSF culture results. The abdominal shunt catheter was externalized in infections restricted to the abdomen.

Results: Median age was 49 yrs. (range 0.3–86 yrs.). Initial surgical treatment consisted of shunt removal (79 cases, 91%; with placement of an EVD: 69 cases, 79%). Microbiological analyses identified coagulase-negative staphylococci (CNS) in 43 (49%), staphylococcus aureus in 6, and gram-negative rods in 7 cases (including 10 cases with multiple microorganisms). Cultures remained negative in 35 cases (40%). Antibiotics were administered for 4-80 days (median 13 days). 53 cases (61%) were initially treated with cefuroxim/flucloxacillin. 40 patients (46%) required more than one course of antibiotics (risk factors: cultures positive for CNS, P=0.001, or gram-negative rods, P=0.043; any positive CSF culture, P=0.001; time since shunt placement 32.2±65.5 vs. 7.7±12.0 months for cases with one vs. more courses of antibiotics, P=0.024). Treatment results did not vary significantly with the initial indications for shunt placement, first vs. recurrent shunt infection and patient age. 19/74 patients (26%) did not require placement of a new shunt.

Conclusions: The frequent isolation of CNS (49%) supports aggressive surgical treatment for shunt infections, since CNS will develop capsules impermeable to antibiotics after colonization of silicon catheters. CNS are resistant to cefuroxim/oxacillin. Hence, our data argue for a different first-line antibiotic treatment (e.g. vancomycin). A considerable number of patients with a shunt infection (i.e. a shunt complication) may not need a shunt at all.