Korean Journal of Cerebrovascular Surgery 2007;9(1):8-13.
Published online March 1, 2007.
Central Nervous System Infection Related to Intracranial Indwelling Catheters.
Park, Chang Kyu , Min, Kyung Soo , Lee, Mou Seop , Kim, Young Gyu , Kim, Dong Ho
Department of Neurosurgery, Chungbuk National University College of Medicine. ygk@chungbuk.ac.kr
Abstract
OBJECTIVE
Infection of the intracranial catheter remains the main morbidity and mortality associated with this procedure. In this retrospective study we have collected the information regarding the occurrence of this disease in order to find ways to reduce the incidence of central nervous system (CNS) infection related to an intracranial indwelling catheter. METHOD: In a six-year retrospective study we selected and reviewed the records of 242 patients (with a total of 314 catheters). We analyzed the incidence of infection, etiologic bacteria and factors affecting the risk of infection: catheter duration, catheter sequence, concurrent craniotomy, subcutaneous tunneling of catheter, cerebrospinal fluid (CSF) draining catheter, urokinase irrigation. RESULTS: Nineteen patients were infected. the infection rate was thus 8%. Staphylococcus aureus and Coagulase-Negative Staphylococcus are the most frequently-involved pathogens. The onset of infection ranged from 6 days to 38 days (with a mean of 14 days). There was a significant association between infection and a CSF draining catheter, a concurrent craniotomy, no subcutaneous tunneling, the duration of the catheter and multiple sequential catheters in the univariate logistic regression model. There was, however, no significant association between a CSF draining catheter and infection in the multivariate logistic regression model. CONCLUSION: The result of this study suggests that long catheter duration, no subcutaneous tunneling, multiple sequential catheters, concurrent craniotomy increase the incidence of CNS infection related to an intracranial indwelling catheter. An intracranial catheter must be placed using aseptic procedures with subcutaneous tunneling and maintenance of a strict closed system alsoshort duration as possible as.
Key Words: CNS infection, Intracranial indwelling catheter, CSF draining catheter (245)

Introduction 


  
Intracranial indwelling catheters are widely used to control hydrocephalus, to drain hematomas and to monitor intracranial pressure. However CNS infections associated with these catheters remain a major complication of the procedure. These infections are directly responsible for deaths and lead to excess hospitalization and it's accompanying annual economic burden. The infection rate for ventriculostomy is reported to be between 0% and 27% in a large number of retrospective and prospective clinical series.1)2)3)5) The infection rate depends on various factors including the patient population, the criteria used to define infection, and the administration of antibiotics. 
   We have performed a retrospective analysis of all patients undergoing intracranial catheter placements over six-year period at our hospital. The objectives of this study are to analyze risk factors for CNS infection related to intracranial indwelling catheters, in order to help prevent the occurrence of infection. 

Materials and Methods 

The charts of 242 patients who underwent a total of 314 
   intracranial catheter placements were reviewed for the following parameters: sex, age, admission diagnosis, results of CSF study, occurrence of CNS infection, risk factors (CSF drainage, duration of catheter placement, concurrent craniotomy, subcutaneous tunneling, sequence of catheter, and irrigation though catheter), treatment. 
   Intracranial indwelling catheters include extraventricular drainage (EVD), cisternal drainage (CISD), intracerebral hematoma drainage (ICHD), subdural drainage (SDD). Prophylactic antibiotics were used in all patients for the duration of catheterization. 
   Diagnosis criteria for CNS infection related to intracranial indwelling catheters are: 1) fever (>38.0℃); 2) CSF pleocytosis (>15cells/mm3); 3) positive CSF culture; 4) no other detectable CNS infection (ex. previous V-P shunt infection, meningitis, brain abscess). If there was no clinical symptom of infection, a catheter tip culture at the time of catheter removal was used instead of CSF culture in patients with non-CSF-draining catheters (SDD, ICHD). The date of the first positive culture was recorded as the date infection occurred. 

Risk factor analysis 
   1) CSF drainage : We divided patients into two groupsthose with catheters draining CSF (EVD, CISD) and those with catheters not draining CSF (ICHD, SDD). In case of patients with both catheters (CSF drainage & no CSF drainage), the patients are deemed to belong to CSF drainage group, because the duration of catheters draining CSF was longer than that of the non-CSF-draining catheters in a such cases. 
   2) Urokinase irrigation through catheters : We divided patients into two groups-those with irrigation through catheters and those without irrigation through catheters. 
   3) Concurrent craniotomy : Patients were divided into two groups-those who had undergone concurrent craniotomy and those who had not undergone concurrent craniotomy. 
   4) No subcutaneous tunneling : Patients were divided into two groups-those with subcutaneous tunneling and those without subcutaneous tunneling. 
   5) Duration of catheter placement : We studied the association between the duration of catheterization and the incidence of infection. 
   6) Multiple sequential catheter : Patients were divided into two groups-those receiving a single catheter and those receiving multiple sequential catheters. 
   The association of a risk factor with the incidence of infection was statically analyzed using a univariate logistic regression model and multivariate logistic regression model. 

Results 

Patient population 
   The study population consisted of 148 males and 94 females with a mean age of 59 years. Admission diagnoses for patients are 69 subarachnoid hemorrhage (SAH), 90 intracerebral hemorrhage ± intraventricular hemorrhage (ICH±IVH), 76 chronic subdural hemorrhage (chronic SDH) and 7 brain tumor & cerebellar infarction . 

Infection group 
   19 patients (M/F:11/8) were infected (Table 1). The incidence of CNS infection related to intracranial indwelling catheters was 8% among patients (19/242persons) and 6% among instances of catheterization (19/314procedures). The incidence of infection in patients with EVD (incidence of ventriculitis) was 14% (16/112persons). Admission diagnoses for the infected patients were SAH (13) and ICH+IVH(6). Infections were caused by staphylococcus aureus in six patients, coagulase-negative staphylococcus in four patients, sphingomonas paucimobilis in two patients, and by alcaligenes xylosoxidans, Pseudomonas aruginosa Escherichia coli, acinetobacter calcoaceticus-baumannii complex, Klebsiella oxytoca Chryseobacterium (Flavobacterium) indologenes, Aerococcus and Citrobacter freundii complex in one patient each. The time elapsing before detection of infection ranged from 6 days to 38 days (mean 14 days). Duration of antibiotics therapy (intravenous) ranged from 18 days to 76 days (mean 31 days). Three patients died due to uncontrolled intracranial pressure. 

Risk factor analysis 
   1) CSF (cerebrospinal fluid) drainage : One-hundred and twelve patients underwent EVD placement and 15 patients underwent CISD placement. Sixteen patients with EVD (14 percent) and three patients with CISD (20 percent) were infected. In the cases of 76 patients with SDD and 39 patients with ICHD, there were no infections patients. Thus, all infected patients had CSF draining catheters. 
   2) Urokinase irrigation through catheters : Of 69 patients who underwent urokinase irrigation through catheters, 8 were infected (11%). Of 173 patients who did not undergo urokinase irrigation through catheters, 11 were infected (8%). 
   3) Concurrent craniotomy : Of 69 patients who underwent concurrent craniotomy, 11 were infected (16%). Of 173 patients who did not undergo craniotomy, 8 were infected (5%). 
   4) No subcutaneous tunneling : Of 187 patients who had catheters with subcutaneous tunneling, 10 were infected (6%). Of 55 patients who had catheters without subcutaneous tunneling, 9 were infected (15%). 
   5) Duration of catheter placement : The duration of catheter placement ranged from 3 days to 38 days (mean 8 days) among all patients in total. The time elapsing until detection of infection ranged from 6 days to 38 days (mean 14 days) (Fig. 1). The daily infection rate, defined as the ratio of the number of infected patients to the number of patients with catheters on that day, suggests an increasing infection risk with time (Fig. 2). 
   6) Multiple sequential catheter : In 181 patients who underwent single-catheter placement, 9 were infected (5%). In 61 patients receiving multiple sequential catheters, 10 patients were infected (16%) (Table 2). 
   Statistical analysis : There was a significant association between infection and catheters draining CSF, concurrent craniotomy, no subcutaneous tunneling, duration of catheter, multiple sequential catheters in the univariate logistic regression model. There was, however, no significant association between infection and catheters draining CSF in the multivariate logistic regression model (Table 3). 

Discussion 

   As mentioned above, the incidence of CSF infection related to intracranial indwelling catheter and ventriculitis in this study was 8% and 14% respectively. The incidence of ventriculitis in this study falls within the previously-reported range of 0% to 27%.1)2)3)5) The true incidence of EVD-related ventriculitis is difficult to assess from the literature, since most studies are retrospective and diagnosis usually relies solely on a positive CSF culture without consideration of clinical and CSF biochemical data. This may lead to an overestimation of infection incidence. 
   There are controversies about the possible link between EVD duration and risk of infection. In 1984, Mayhall et al reviewed the Medical College of Virginia’s data base and reported increased risk of infection in patients with ventriculostomy in place for more than five days. They recommended that "if monitoring is required for more than five days, the catheter should be removed and inserted at a different site".5) In contrast, others suggested that duration of monitoring was not a risk factor associated with infection. In 1996, Holloway et al re-examined the Medical College of Virginia’s original recommendations regarding prophylactic catheter exchange. Reviewing the incidence of ventriculitis in 584 severely head-injured patients with EVDs from the Traumatic Coma Data Bank and the Medical College of Virginia Data Bank, they found a non-linear relation between duration of EVD placement and ventriculits. These authors found no support for the routine exchange of ICP if monitoring is required for more than five days.2) Kanter et al. reported that the risk of infection began to decrease after day six, and that infection became very unlikely after day 11.3) Hypotheses regarding the etiology of infection of catheters center on two alternative assumptions: 1) contamination leading to infection occurs at the time of insertion, implying that catheter duration has minimal effect on infection risk; and 2) infection of the catheter derives from catheter contamination after insertion, suggesting that duration of catheter use may significant affect infection risk. Our data demonstrate an increasing infection risk with time. These data corroborate the findings of Mayhall et al. A possible weakness in the data is that CSF samples were not routinely withdrawn on a day to day basis, but only when a catheter was placed or withdrawn or when infection was suspected. It is unknown whether some of the infections could have been discovered if CSF had been routinely sent for analysis each day. 
   Prophylactic antibiotic use with EVD is also controversial. It has been recommended that prophylactic antibiotics be administered at the time of insertion only, or throughout the entire EVD duration. Rebuck et al. found that antibiotics administration, however long, did not decrease the incidence of CSF infection.6) Alleyne et al. demonstrated that prophylactic antibiotics given for the duration of the EVD did not reduce the ventriculitis rate compared with procedural administration.1) In our study, because all patients received prophylactic antibiotics throughout the duration of catheterization, we could not research the association between prophylactic antibiotics and incidence of infection. 
   Routine culture of CSF is common practice in patients with EVDs. The main purpose of this procedure is to identify infections early so as to avoid complications related to bacterial ventriculitis. But routine culture of CSF is also controversial. The findings of Walter et al. do not support the routine analysis of CSF in patients with EVD in place. A protocol in which CSF cultures are performed for new fever or peripheral leukocytosis, neurological deterioration, or development of turbid CSF should identify infections in a timely fashion. An important caveat is that this protocol is not applicable to patients in whom fever might be masked, for example by corticosteroid treatment or by hypothermia induced to treat raised ICP associated with severe head injury.9) Rogier et al. also advocated limited value of routine CSF analysis.7) 
   Subcutaneous tunneling in catheter placement was shown to be efficient in preventing EVD infection and displacement in some literatures.4) In our study, there was a significant association between subcutaneous tunneling and infection. There is a tendency to omit subcutaneous tunneling in catheter placement in emergent situations. But because subcutaneous tunneling in catheter placement does not take a long time to do, conducting this procedure routinely may prove a simple way of decreasing the incidence of infection. Holloway et al. found a significant association between craniotomy and ventriculitis in their study.2) Our data corroborate their findings. 
   We found that there were no infected patients with non-CSF-draining catheters. We thus proposed the hypothesis that CSF-draining catheters increase the incidence of CNS infection related to intracranial indwelling catheter. There was a significant association between CSF drainage through catheter and infection in the univariate logistic regression model; there was no significant association in the multivariate logistic regression model. This result may be due to statistical bias, as patients with CSF-draining catheters had more different risk factors (concurrent craniotomy, long catheter duration, no subcutaneous tunneling) than patients with non-CSF draining catheters. Evaluation of future studies which concentrate on controlling bias may support this hypothesis even though this retrospective study could not do so. 
   Treatments for ventriculitis include continuous drainage of CSF, removal of the infected catheter, intermittent replacement of the catheter, and intravenous and/or intraventricular antibiotics.5)8) The indication of intraventricular antibiotics may be for organisms not sensitive to antibiotics that cross through non-inflamed blood-brain barrier (especially gram-negative organisms), severe ventriculitis, or those organisms unresponsive to systemic therapy.10) 

Conclusion 

   The result of this study suggests that long catheter duration, no subcutaneous tunneling, multiple sequential catheters, and concurrent craniotomy increase the incidence of CNS infection related to intracranial indwelling catheters. Intracranial catheters must be placed by aseptic procedures with subcutaneous tunneling and maintenance of a strict closed system also short duration as possible as. We suggest further study into the association between CSF- draining catheters and infection. 


REFERENCES


  1. Alleyene CH Jr, Hassan M, Zabramski JM. The efficacy and cost of prophylactic and periprocedural antibiotics in patients with external ventricular drains. Neurosurgery 47:1124-9, 2000 

  2. Holloway KL, Barnes T, Choi S, Bullock R, Marshall LF, Eisenburg HM, et al. Ventriculostomy infections : the effect of monitoring duration and catheter exchange in 584 patients. J Neurosurg 85:419-24, 1996 

  3. Kanter RK, Weiner LB, Patti AM, Robinson LK. Infectious complications and duration of intracranial pressure monitoring. Crit Care Med 13:837-9, 1985 

  4. Khanna RK, Rosenblum ML, Rock JP, Malik GM. Prolonged external ventricular drainage with percutaneous long-tunnel ventriculostomies. J Neurosurg 83:791-4, 1995 

  5. Mayhall CG, Archer NH, Lamb VA, Spadora AC, Baggett JW, Ward JD, et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med 310:553-9, 1984 

  6. Rebuck JA, Murry KR, Rhoney DH, Michael DB, Coplin WM. Infection related to intracranial pressure monitors in adults: analysis of risk factors and antibiotic prophylaxis. J Neurol Neurosurg Psychiatry 69:381-4, 2000 

  7. Rogier PS, Janke S, Freek WC, Ronald BG, Leo GV, Marc CV, et al. Lack of value of routine analysis of cerebrospinal fluid for prediction and diagnosis of external drainage-related bacterial meningitis. JNeurosurg 104:101-8, 2006 

  8. Sim KB, Chung CK, Kim DG, Han DH. Risk factors of ventriculitis following ventriculostomy. J Korean Neurosurg Soc 23:553-60, 1994 

  9. Walter JH, Paul S. The value of routine cultures of the cerebrospinal fluid in patients with external ventricular drains. Neurosurgery 46:1149-53, 2000 

  10. Wen DY, Haubes SJ. Management of infected cerebrospinal fluids in infants and children. Contemp Neurosurg 13(11):1-5, 1991

TOOLS
METRICS Graph View
  • 678 View
  • 1 Download
Related articles

Current State and Future in Interventional Treatment of Intracranial Aneurysm.2003 March;5(1)



ABOUT
BROWSE ARTICLES
EDITORIAL POLICY
FOR CONTRIBUTORS
Editorial Office
The Journal of Cerebrovascular and Endovascular Neurosurgery (JCEN), Department of Neurosurgery, Wonkwang University
School of Medicine and Hospital, 895, Muwang-ro, Iksan-si, Jeollabuk-do 54538, Korea
Tel: +82-2-2279-9560    Fax: +82-2-2279-9561    E-mail: editor.jcen@the-jcen.org                

Copyright © 2024 by Korean Society of Cerebrovascular Surgeons and Korean NeuroEndovascular Society.

Developed in M2PI

Close layer
prev next