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Meta-Analysis
. 2019 Jun 4;6(6):CD012902.
doi: 10.1002/14651858.CD012902.pub2.

Route of antibiotic prophylaxis for prevention of cerebrospinal fluid-shunt infection

Sebastian Hhmj Arts  1 , Hieronymus Damianus Boogaarts, Erik J van Lindert
Affiliations
Meta-Analysis

Route of antibiotic prophylaxis for prevention of cerebrospinal fluid-shunt infection

Sebastian Hhmj Arts et al. Cochrane Database Syst Rev. .

Abstract

Background: The main complication of cerebrospinal fluid (CSF) shunt surgery is shunt infection. Prevention of these shunt infections consists of the perioperative use of antibiotics that can be administered in five different ways: orally; intravenously; intrathecally; topically; and via the implantation of antibiotic-impregnated shunt catheters.

Objectives: To determine the effect of different routes of antibiotic prophylaxis (i.e. oral, intravenous, intrathecal, topical and via antibiotic-impregnated shunt catheters) on CSF-shunt infections in persons treated for hydrocephalus using internalised CSF shunts.

Search methods: We conducted a systematic electronic search without restrictions on language, date or publication type. We performed the search on the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase, with the help of the Information Specialist of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. The search was performed in January 2018.

Selection criteria: All randomised and quasi-randomised controlled trials that studied the effect of antibiotic prophylaxis, in any dose or administration route, for the prevention of CSF-shunt infection in patients that were treated with an internal cerebrospinal fluid shunt. Patients with external shunts were not eligible.

Data collection and analysis: Two review authors independently extracted data from included studies. We resolved disagreements by discussion or by referral to an independent researcher within our department when necessary. Analyses were also performed by at least two authors.

Main results: We included a total of 11 small randomised controlled trials, containing 1109 participants, in this systematic review. Three of these studies included solely children, and the remaining eight included participants of all ages. Most studies were limited to the evaluation of ventriculoperitoneal shunts. However, five studies included participants with ventriculoatrial shunts, of which one study contained four participants with a subduroperitoneal shunt. We judged four out of 11 (36%) trials at unclear risk of bias, while the remaining seven trials (64%) scored high risk of bias in one or more of the components assessed.We analysed all included studies in order to estimate the effect of antibiotic prophylaxis on the proportion of shunt infections regardless of administration route. Although the quality of evidence in these studies was low, there may be a positive effect of antibiotic prophylaxis on the number of participants who had shunt infections (RR 0.55, 95% CI 0.36 to 0.84), meaning a 55% reduction in the number of participants who had shunt infection compared with standard care or placebo.Within the different administration routes, only within intravenous administration of antibiotic prophylaxis there may be evidence of an effect on the risk of shunt infections (RR 0.55, 95% CI 0.33 to 0.90). However, this was the only route that contained more than two studies (8 studies; 797 participants). Evidence was uncertain for both, intrathecal administration of antibiotics (RR 0.73, 95% CI 0.28 to 1.93, 2 studies; 797 participants; low quality evidence) and antibiotic impregnated catheters (RR 0.36, 95% CI 0.10 to 1.24, 1 study; 110 participants; very low quality evidence) AUTHORS' CONCLUSIONS: Antibiotic prophylaxis may have a positive effect on lowering the number of participants who had shunt infections. However, the quality of included studies was low and the effect is not consistent within the different routes of administration that have been analysed. It is therefore uncertain whether prevention of shunt infection varies by different antibiotic agents, different administration routes, timing and doses; or by characteristics of patients, e.g. children and adults. The results of the review should be seen as hypothesis-generating rather than definitive, and the results should be confirmed in adequately powered trials or large multicentre studies in order to obtain high-quality evidence in the field of ventricular shunt infection prevention.

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Conflict of interest statement

SA ‒ none

HB ‒ none

EvL ‒ none

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 Treatment benefit of antibiotic prophylaxis versus no antibiotic prophylaxis, outcome: 1.1 Number of participants experiencing shunt infection after administration of antibiotics.
1.1
1.1. Analysis
Comparison 1 Treatment benefit of antibiotic prophylaxis versus no antibiotic prophylaxis, Outcome 1 Number of participants experiencing shunt infection after administration of antibiotics.
2.1
2.1. Analysis
Comparison 2 Treatment benefit of antibiotic prophylaxis in adults and children, Outcome 1 Number of adults and children experiencing shunt infection after administration of antibiotic prophylaxis.
3.1
3.1. Analysis
Comparison 3 Treatment benefit of antibiotic prophylaxis in ventriculoperitoneal shunts and ventriculoatrial shunts, Outcome 1 Number of participants experiencing shunt infection after administration of antibiotics in ventriculoperitoneal shunts versus ventriculoatrial shunts.
4.1
4.1. Analysis
Comparison 4 Treatment benefit of antibiotic prophylaxis for different antibiotic agents, Outcome 1 Number of participants experiencing shunt infection for different antibiotic agents.
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis (Trials at low risk of bias and trials at uncertain and high risk of bias), Outcome 1 Number of participants experiencing shunt infection after administration of antibiotics.
6.1
6.1. Analysis
Comparison 6 Sensitivity analysis on differences in control groups between studies (placebo, common care, no antibiotics), Outcome 1 Sensitivity analysis on differences in control groups between studies.
See this image and copyright information in PMC

Update of

References

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References to other published versions of this review

Arts SHHMJ at al, 2017
    1. Arts SHHMJ, Boogaarts HD, Lindert EJ. Route of antibiotic prophylaxis for prevention of cerebrospinal fluid‐shunt infection. Cochrane Database of Systematic Reviews 2017, Issue 12. [DOI: 10.1002/14651858.CD012902] - DOI - PMC - PubMed

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