Korean Journal of Cerebrovascular Surgery 2007;9(1):56-60.
Published online March 1, 2007.
Ventriculostomy-Associated Infection : Analysis of Risk Factors and the Venue of External Ventricular Drainage.
Choi, Jong Moon , Cho, Do Sang , Jin, Sung Chul , Kim, Sung Hak , Park, Dong Been , Kim, Young Rae
Department of Neurosurgery, College of Medicine, Ewha Womans University, Seoul, Korea. drcho@ewha.ac.kr
Abstract
OBJECTIVE
The purpose of this study is to evaluate the risk factors for ventriculostomy-associated infections (VAI) and to examine the differences among VAI according to the venue of catheter placement in our institute. Materials and METHODS: During a four-year period, 114 patients of the neurosurgical intensive care unit (NICU) who received an external ventricular drainage (EVD), were retrospectively studied. The use of prophylactic systemic antibiotics was not included in the evaluation of the risk factors for VAI, because this was applied to all patients in our trial. RESULTS: One hundred sixty-five catheters were placed, in 114 patients, among whom 7.9% developed ventriculitis. The risk of VAI was not significantly associated with age, intial Glasgow coma scale (GCS) score, indication for the catheter, craniotomy, duration of catheter, DM, hypertension and repeated catheter insertion. Furthermore, EVD catheterization in non-operating places was not associated with a trend toward higher VAI as well. CONCLUSION: Risk factors for an increased incidence of VAI were not observed in our trials. In our study, the risk of VAI was not associated with the venue of catheter placement. These findings suggest that EVD catheter insertion in non-operating places may be a safe procedure without the risk of VAI.
Key Words: Ventriculitis, Ventriculostomy, External ventricular drainage

Introduction 


  
Ventriculostomy catheter, also known as external ventricular drainage (EVD), is commonly used in neurosurgical patients for monitoring intracranial pressure and for the therapeutic drainage of cerebrospinal fluid (CSF). As with any surgically implanted foreign body, the use of these catheters is known to be associated with a risk of infection.6) This study was conducted to assess the factors associated with ventriculostomy-associated infection (VAI) and to assess the differences among VAI according to the venue of catheter placement. 

Materials and Methods 

   All neurosurgical patients who received an EVD during the four-year period from 2003 to 2006 were included in the retrospective study. Data were collected for each patient on standardized forms and included age, sex, primary neurological diagnosis, baseline Glasgow coma scale (GCS) score, patient disposition at discharge, diabetes mellitus (DM), hypertension (HTN), and Glasgow outcome scale (GOS). In our study, risk factors for VAI included the venue of EVD placement (operating room or non-operating places), duration of EVD, number of the times of EVD catheter, trauma, and intraventricular hematoma. The differences among VAI according to the venue of EVD placement were evaluated as being important because the previous literature suggested that EVD catheter insertion should be performed in the operating room, even if EVD catheterization in nonoperating places did not statistically influence the incidence of VAI. 
   All patients received antibiotic therapy with third generation cephalosporin intravenously before ventricular catheter placement. After scalp shaving and preparation with chlohexidine-alcohol solution and Betadine scrubTM, a silicone catheter was inserted through a precoronal hole into the ventricles. The catheter was tunnelled subcutaneously 3 cm to 5 cm away from the insertion site. The drainage system (Drainage circuit & BagTM, Yushin Medical) was then connected to the catheter, and the three-way tap was protected with a sterile dressing, covering the entire head. A CSF sampling was routinely sent to the laboratory for biochemistry, cell count, Gram stain and culture twice a week. Prophylactic intravenous antibiotics with third generation cephalosporin and aminoglycoside were given to all patients for the duration of catheterization. 
   The definition of CSF infection was adapted from the Centers for Disease Control (CDC) guidelines.3) CSF infection had to meet at least one of the following two criteria: (1) presence of an organism isolated from CSF culture; and/or (2) fever (>38℃) in the absence of other recognised causes with the institution of appropriate antimicrobial therapy and any of the following: (a) increased white cells (>50% polymorphonuclear leukocytes), increased protein, and/or decreased glucose (<15 g/dl) in CSF, or (b) organism on CSF Gram stain. 
   Data were entered, validated, and analyzed using SPSS. software (version 12.0 SPSS Inc., Chicago, IL, USA). Continuous values were evaluated with t-test and categorical values were assessed using chi-square test or Fisher exact test. Logistic regression analysis was performed to determine factors relevant to the risk of CSF infection, expressed as odd ratios (OR) and 95% confidential interval (CI). 

Results 

   During the study period, 114 patients (47 female and 67 male patients) aged from 22 years to 81 years of age (mean age 57.6) were included. Their diagnoses are summarized in Table 1. A total of 168 EVD were inserted. The catheters remained in place between 1 and 90 days (mean 12.3 days). Nine cases of VAI were detected, giving a cumulative infection incidence of 7.9 % per patient and 8.9% per procedure. 
   Patient characteristics were similar between the infected and non-infected groups (age, sex ratio, EVD indication). The main indications for EVD insertion were spontaneous intracerebral and/or intraventricular hemorrhage (IVH) (55.3%) and subarachnoid hemorrhage (SAH) (26.3%). Table 2 shows the risk factors for VAI. In previous several studies, risk factors for developing VAI were the diagnosis of IVH, SAH, craniotomy, duration of catheterization.4)7)9)13) However, these factors were not associated with the increase of VAI in our trial. 
   Table 3 compares patients whose ventriculostomy was performed in the operating room with those whose was done in non-operating places. Patient characteristics between these two groups are not statistically significant. There was not a trend toward a reduction in the infection rate for catheters placed in the operating room compared with nonoperating places like in previous studies.4)7)9)13)15) Serious complications such as subdural empyema, and brain abscess did not develop in the group that EVD catheter insertion was performed in non-operating places. 
   Of the 9 VAI episodes, 3 cases were clinically diagnosed. In the other 6 cases, there were 9 isolates. Staphylococcus epidermidis (Methicillin resistant) was the leading pathogen (44.4%) followed by Acinetobacter baumannii (22.2%). Enterococcus (Vancomycin resistant) and Pseudomonas and Staphylococcus hemolyticus were the other pathogens of VAI. 

Discussion 

   The EVD is a life-saving treatment in acute obstructive hydrocephalus due to IVH and to some tumors. EVD can be considered as the first line of treatment for the control of raised intracranial pressure by allowing CSF drainage in case of SAH or head trauma. However, CSF infection and bacterial meningitis caused by contaminated catheters may become life-threatening complications. Previous studies has evaluated the risk factors and the early detection tools of VAI for the purpose of reducing its occurrence. 
   The true incidence of VAI is difficult to assess from the previous literature, because not only does diagnosis usually rely chiefly on a positive CSF culture without consideration of the clinical and CSF biochemical data in most studies,4)5)9)17) but there are also a considerable number of various definitions. This explains, at least in part, the great reported variability in the incidence of reported VAI, which may range from 0 to 40%.6)12) 
   There are controversies about the possible link between EVD duration and the risk of infection. Paramore and Turner11) demonstrated a progressive increase in the daily infection rate with a maximal risk on day 6 of catheter placement. Similarly, Holloway et al.4) demonstrated an increased risk of VAI during the first 10 days after catheter placement, which reached a plateau thereafter. In contrast, others have suggested that the EVD duration was not a risk factor associated with infection.10)11)17) In fact, VAI may be due to contamination associated with EVD catheter insertion, as reflected by the occurrence of early infection and by the increased risk in patients requiring multiple catheters,2) or to a delayed contamination during EVD care.5) In our study, the duration of EVD and the number of catheters inserted per patient was similar between the infected and uninfected groups. These results led to the conclusion that EVD duration is not a risk factor for VAI, as long as careful hygiene is maintained. 
   Several studies addressed the relationship between neurosurgical procedures and VAI,4)7)8)9)13)15) while a positive association was shown in most other studies. Mayhall et al.9) noted that 68% of patients with VAI as compared with only 40% of uninfected patients underwent neurosurgical procedures which were statistically significant. However, our study demonstrated that the risk of VAI was not related to the operation of craniotomies. The reasons for this might result from the use of prophylactic intravenous systemic antibiotics, the development of operating procedures and an improvement in perioperative care. 
   Most previous studies found a strong association between hemorrhagic CSF and the development of VAI.1)4)7)8)9)14)16) Sundbarg et al.16) reported a 10% infection rate in patients with SAH and a 13.2% infection rate for patients with spontaneous intracerebral hemorrhage as compared with rates of 0 to 2.6% for patients with all other diagnoses. However, hemorrhagic CSF was not associated with the incidence of VAI in our trials. This result suggested that latent confounding factors such as intermittent catheter malfunction caused by hemorrhagic CSF influenced the different results between previous studies and ours. 
   We postulated that the presence of DM would increase the risk of VAI. In general, the risk of postoperative wound infection and systemic infection is higher in patients who have DM than in patients who do not. Although some studies have examined the relationship between systemic infections and VAIs, no literature that investigated the relationship between DM and VAIs has been found. Holloway et al.4) reported a 20.7% incidence of VAI in patients with sepsis as compared with only 8.6% in those without sepsis. However, in our series, we found that the presence of DM did not independently increase the risk of VAI in statistical significance. 
   The placement of ventriculostomy in non-operating places was not significantly associated with VAI in our trial. No statistically significant differences in infection rates were noted according to the venue of ventriculostomy. However, Clark et al.2) noted that the incidence of major infectious complications (e.g., clinical ventriculitis, subdural empyema, brain abscess) was higher in the group that had received implants in the intensive care unit. Other studies have suggested that ventriculostomy in the operating room may be more beneficial than in other places if possible. However, although it is important to perform EVD in a clean place (e.g., operating room), considering the results of our trial, we may regard timely and rapid treatment of critically ill patients as the more significant point of treatment. 
   The drawbacks of our study include the retrospective method of data collection, which results in selection bias and which restricts our ability to obtain more important information such as recording the results of breaks, and obstruction. In addition, the confounding factor such as prophylactic antibiotics treatment which might influence the incidence of VAI was not evaluated. The study was conducted in a single center, and the sample size might limit the interpretation of subgroup analysis. 

Conclusion 

   In our study, unlike in the previous literature, the duration of catheter placement, craniotomy and hemorrhagic CSF were not associated with the incidence of VAI. Also, the risk of VAI was not associated with the venue of catheter placement. These findings suggest that immediate EVD catheter insertion in non-operating places may be a safe procedure without the risk of VAI. 


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