87

PAPER

Zero tolerance to shunt infections: can it be achieved?

M S Choksey, I A Malik
...............................................................................................................................

See end of article for J Neurol Neurosurg Psychiatry 2004;75:87–91

authors’ affiliations
.......................
Correspondence to:
Mr M S Choksey,
Department of
Neurosurgery, University
Hospitals Coventry &
Warwickshire NHS Trust, Objective : To evaluate the rigid application of a technique of shunt placement aimed at the eradication of
Walsgrave Hospital, postoperative shunt infection in neurosurgical practice.
Bridge Road, Coventry Method: All shunt procedures were performed or closely supervised by the senior author (MSC). The
CV2 2DX, UK;
munchi.choksey@ essentials were the use of intravenous peri- and postoperative antimicrobials, rigid adherence to classical
wh-tr.wmids.nhs.uk aseptic technique, liberal use of topical antiseptic (BetadineH), and avoidance of haematomas.
Results: Of 176 operations, 93 were primary procedures; 33 patients underwent revisions, some multiple.
Received Only one infection occurred, seven months postoperatively, secondary to appendicitis with peritonitis. The
5 November 2002
Revised accepted infecting Streptococcus faecalis appeared to ascend from the abdominal cavity.
1 May 2003 Conclusion: A rigidly applied protocol and strict adherence to sterile technique can reduce shunt infections
....................... to a very low level.

I
nfection remains a serious complication of shunt implan-
tation, with a mortality rate ranging from 1.5–22%.1 2 Those
who survive risk intellectual, cognitive, and neurological
deficits.3 Infection has been reported to occur in 5–15% of
shunt procedures.4–6 However, some authors have described
lower infection rates ranging from 0.3– 5%.7–12
Many factors have been associated with shunt infection,
including the age of the patient,1 13–15 the aetiology of
hydrocephalus,1 and the type of shunt implanted.16 17 Most
studies of the use of prophylactic antibiotic medications have
given inconclusive results,2 7 15 18–24 and there has been no
definite evidence that prophylactic antimicrobial medications
reduce shunt infection rates. Other factors such as timing of
the operation (elective/emergency), duration of surgery,
number of operations/patient, number of people in the
operation room, and length of time during which the shunt
material is exposed to the atmosphere have been highlighted
as contributing to shunt infection; these may all be included
in specific ‘‘theatre discipline’’.
In January 1994, the senior author (MSC) established a
strict protocol for shunt placement with vigorous attention to
asepsis, antisepsis, and perioperative antimicrobial therapy.
We report the results of 176 shunt procedures in 126 patients
over a period of seven and a half years.
METHODS
Between January 1994 and mid-July (15th) 2001, 126
patients underwent shunt insertions and revision procedures
in the Department of Neurosurgery at University Hospitals
Coventry & Warwickshire NHS Trust, Walsgrave. A total of
176 shunt procedures were performed in 126 patients with
hydrocephalus. Although the majority of procedures involved
ventriculoperitoneal shunts, a variety of other shunts were
also inserted, including lumboperitoneal, cystoperitoneal,
ventriculopleural, syringopleural, and ventriculoatrial shunts.
Primary shunt procedures had been performed previously at
other centres in 33 patients; these patients underwent shunt
revision for various reasons, and have been included in this
study. All shunt material removed during revision was sent
for bacteriological analysis.
Operative technique
All operations were carried out in a dedicated neurosurgical
operating theatre, which was seldom, if ever, used for general
surgical cases. The operating theatre personnel were all
neurosurgically trained. Most operations were carried out by
single surgeons. All operating theatre staff were reminded
that a shunt procedure was in progress, and strict aseptic
sterile technique was observed throughout. Lapses in theatre
discipline were not tolerated, and this attitude was inculcated
into all present; we term this ‘‘zero tolerance’’. All ingress and
egress from the operating theatre was prohibited except for
genuine emergencies. The number of operating theatre
personnel varied between five and seven. All personnel wore
full operating theatre dress, including facemasks. A wide area
was cleared around the operating table itself, so that the
diathermy, suction, and anaesthetic machines were kept well
away from the sterile area.
Intravenous antibiotics were given with the induction of
general anaesthesia to all patients, in most cases benzylpe-
nicillin 1.2 gm and flucloxacillin 1 gm intravenously. Those
who were allergic to penicillin were given rifampicin 600 mg
intravenously with induction. The patient was positioned
on the operating table in the anaesthetic room (details of
the operating theatre and the preparation solutions used are
given in the Appendix). The head, trunk, and abdomen
were lathered with BetadineH surgical scrub, and shaved
widely with a sterile cut throat razor. MSC’s preference
was to use a right frontal burr hole whenever possible,
and therefore the pinna of the ear was carefully taped
forwards.
The skin was prepared using a solution of chlorhexidine
and cetrimide, followed by alcoholic BetadineH. The incisions
were marked with a sterile pen and then draping was carried
out, using sterile adhesive drapes (KlinidrapesH, by
Molnlycke), to outline the operative area, followed by a
transparent sterile drape (IobanH) impregnated in BetadineH.
Two further layers of standard towels were then used to
drape the patient right down to floor level, so that no part of
the operating theatre table was exposed. Finally, the sterile
drape was daubed with a further layer of alcoholic BetadineH,

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which was allowed to dry while the surgeon left the operating
room to put on sterile dress.
The skin incisions were then carried out and a swab soaked
in aqueous BetadineH placed in the incisions, with particular
care to soak the exposed skin edges. The burr hole was made,
the abdominal cavity opened by a transverse right upper
quadrant incision, and a small intervening stab incision was
added just above the ligamentum nuchae about 5 cm behind
the ear. Two separate shunt tunnellers were daubed with
aqueous BetadineH and positioned subcutaneously. The
interior of each tunneller was then irrigated with aqueous
BetadineH solution. Having completed all the preparation for
shunt placement, including opening of the dura and
diathermy of the cortical surface, the operating surgeon’s
gloves were washed with aqueous BetadineH and covered
with a further pair of sterile gloves. Only then was the shunt
system opened and placed upon a separate trolley, using
sterile instruments that had not been in contact with the
skin. In the majority of cases Delta valves (PS Medical) were
chosen, with a Medtronic barium-impregnated catheter,
without biocide.
The shunt system was irrigated with 5 mg of intrathecal
gentamicin, made up in theatre with saline to 5 ml. The
ventricle was tapped using a Dandy needle, and a further
5 mg of intrathecal gentamicin, made up to 5 ml with saline,
was injected slowly into the ventricles, with frequent back
and forth aspiration and injection, to ensure thorough mixing
with ventricular CSF. The shunt system was tunnelled down
to the peritoneal cavity, with care to keep it away from the
skin on a separate sterile towel.
The ventricular catheter was inserted and cut to length
with new, sterile scissors. The connection between the
ventricular catheter and the shunt was made as quickly as
possible, handling the shunt with fingers once again soaked
in BetadineH. The ventricular catheter was tied to the shunt
with a heavy silk tie (2/0 or larger), to avoid the risk of
cutting through the shunt catheter. The shunt was then
pulled down, and checked to ensure that it was free of kinks
and dripping well. The burr hole was lined with surgicel, and
bone wax used to cover the burr hole defect and reduce the
risk of CSF leakage. The distal end of the shunt was placed in
the peritoneal cavity. Haemostasis was ensured. The wounds
were then closed using VicrylH, sprayed with BetadineH dry
powder spray, followed by sterile OpsiteH dressing spray, and
covered with MeporeH dressings. Strict instructions were
given that the dressings should not be disturbed until the
staples were due for removal at seven days (14 days for
infants).
Postoperatively, patients were maintained on the same
intravenous antibiotics for a further 48 hours, and were
mobilised as soon as they were fit. Under no circumstances
were patients allowed to have the staples removed by any
agency other than the nurses on the neurosurgery unit, under
clean conditions.
Follow up
The follow up period ranged from 16 to 90 months (table 1).
All patients who had had shunt insertions were allowed free
access directly to the neurosurgical unit at any time. The
follow up periods for three patients were curtailed by death.
Table 1 Duration of follow up of patients
Follow up Number of Number of Number of
(years) patients revisions infections
1 126 32 1 Ventriculopleural
1–2 118 27 0 Syringopleural
Over 2 114 28 0 Ventriculoatrial
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Choksey, Malik
Of these, two died as a result of their high grade tumours,
and one was killed in a road traffic accident. No other
patients were lost to follow up.
Criteria for CSF shunt infection
We observed the criteria for CSF shunt infection defined by
Odio et al.25 Shunt infection was considered present when a
pathogenic organism was cultured from lumbar or ventri-
cular CSF, or blood. In addition, a shunt infection was also
considered present if the patient developed a pyrexia higher
than 38.5oC, shunt malfunction, or abdominal or neurologi-
cal symptoms; these findings were attributed to infection
even if cultures were negative.
Statistical analysis
The statistical analysis of this series was to a degree limited
by the absence of controls. However, there is sufficient
literature to justify the assumption that the expected level of
infection lies between 5 and 15%. At the 5% level, we would
have expected 9 infections; at the 15% level, 27 infections.
After discussion with our statisticians, we applied the Fisher
one-sided exact test to our data.
RESULTS
Between 1994 and 2001, a total of 176 shunt procedures were
performed in 126 patients with hydrocephalus. The details of
the patients in this series are set out in tables 2–8. Eight
patients required emergency shunt revision for imminent
death or blindness. The remaining 168 procedures were
performed on the next routine operating list, usually within
24 hours (table 5). The reasons for shunt revision are given in
table 7; the majority were in patients with neural tube
defects. The duration of the procedures varied from 45 to 95
minutes.
Statistical analysis
The observed infection rate was one patient out of 176
(0.57%). Applying the Fisher exact one-sided test, and
assuming an expected infection rate of 5% (nine infections),
the significance was 0.01 (p ,0.01). At the 15% expected
infection rate, the significance was greater (p ,0.0001).
These statistical tests show a highly significant reduction in
shunt infection when compared with historically accepted
data.
Our single infection was seen in an 18 year old patient with
aqueduct stenosis. Before transfer to our unit, he had had
multiple procedures performed at another institution, includ-
ing external ventricular drainage for haemorrhage following
a shunt operation. When his CSF cleared, we inserted a
shunt. His infection occurred seven months after this last
procedure, and appeared to follow appendicitis and perito-
neal sepsis. His shunt and ventricular CSF both grew
Streptococcus faecalis. Although included in this series, this
infection may not have been directly attributable to the shunt
placement.
DISCUSSION
Shunt infection remains a potent cause of mortality and
morbidity. The quoted infection rate ranges from 5–
Table 2 Shunt type
Shunt Number performed Percentage of total
Ventriculoperitoneal 161 91.5
Lumboperitoneal 7 4.0
Cystoperitoneal 3 1.7
2 1.1
2 1.1
1 0.6
Reduction of shunt infections 89

Table 3 Patient details Table 5 Timing of procedures

Patient details Number of patients Percentage of total Timing of procedure Number of procedures Percentage of total

Male 68 54 Elective (within 24 hours) 168 95.5

Female 58 46 Emergency (out of hours) 8 4.5
Preterm infants 6 4.8
Full term infants 2 1.6
2–5 years 11 8.7
6–59 years 81 64.2
60+ years 26 20.6
Table 6 Aetiology of hydrocephalus
Aetiology Number of cases Percentage of cases

Congenital malformations 35 27.8

Table 4 Number of first procedures and revisions Tumours 28 22.2
Subarachnoid 19 15.1
Procedure Number of cases Number of procedures haemorrhage
Meningitis 10 7.9
First ever 89 89 Normal pressure 12 9.5
One revision 26 (2662 = 52) 52 hydrocephalus
Two revisions 9 (963 = 27) 27 Intraventricular 6 4.7
Three revisions 2 (264 = 8) 8 haemorrhage
Total 126 176 Cysts 6 4.7
Miscellaneous 10 7.9

27%,1 11 22 25 28 29 31 34 with most between 5% and 15%. This is

one reason for the recent interest in alternative CSF diversion
procedures that do not involve implanted prostheses; of
these, third ventriculostomy is the most commonly carried
out.
Different studies have pointed to a variety of factors that
may possibly be responsible for shunt infection. Age,26 27 skin
condition,28 gender, pathology, aetiology of the hydrocepha-
lus,21 and immunological status of the patient1 have all been
implicated. Surgical factors that have been studied are length
of preoperative hospitalisation, duration of surgery, number
of revisions,1 type of material used,25 29 30 aseptic technique,44
and prophylactic antibiotics.1 4 11 31 32
The bacteria that most frequently appear in shunt
infections are staphylococci (S epidermidis and aureus)1 10 18 33;
the percentage varies from 62–90%.1 10 18 33 Infections due to
Gram negative bacteria are infrequent but important, because
mortality is very high at 40–90%.1
The variation in quoted infection rates may partly be
caused by different study designs. The incidence of infection
is related either to the number of patients29 35 36 or to the
number of procedures, inclusive of revisions.1 28 Clearly,
infection rates per patient will be higher than infection rates
per procedure, as in any series many patients will have
multiple procedures.
In some series28 37 there was no difference in infection rate
between initial and revision shunt procedures. However, Odio
et al showed an increased risk of CSF shunt infection in shunt
revisions.25 Meirovitch in contrast reported a similar rate of
shunt infection in primary and shunt revision operations.38
This is in accordance with our study, where there was no
increase in the shunt infection rate with revisions. There are
many reports demonstrating an increased risk of infection in
the younger age group.11 28 38 George et al found a significantly
increased rate of infection in children and the elderly.1
Kontny et al39 found no significant difference in the rates of
infection in different age groups, which corresponds with our
results. In concordance with other studies such as that of
Shoenbaum and Gardner,5 we did not see a significant
difference in infection rates with implantation of different
types of shunts for CSF diversion procedures. In parallel with
Kontny et al39, we did not observe any significant difference
in infection rates according to different aetiologies of
hydrocephalus.
The use of prophylactic antimicrobials remains controver-
sial.4 11 31 32 In a recent control study, the infection rate was
6.25% in patients without antibiotic prophylaxis as compared
with 2.56% in patients with antibiotic prophylaxis.26 This
difference was not found to be statistically significant. At
present, the benefit of perioperative antimicrobial prophy-
laxis remains unestablished. As CSF shunt infections con-
tinue to be common and life threatening for patients with
hydrocephalus, we give prophylactic antibiotics to our
patients. The regimen used in this series (penicillin,
flucloxacillin) may be criticised for lack of Gram negative
cover. However, the vast majority of shunt infections are
caused by Gram positive cocci, and the senior author (MSC)
has used this regimen successfully for over 12 years, including
the use of rifampicin, although this may be controversial.

Table 7 Reasons for revision of shunt

Reason for revision Number of cases

Infection 1
Mechanical failure 36
Slit ventricle syndrome 9
Abdominal pseudocyst 1
Disconnection/fracture 7
Shunt migration 10
Overdrainage 14
Underdrainage 8
Haemorrhage 1

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Table 8 Age groups and interval between shunt
insertion and subsequent revision
Interval 0–1 years 1–5 years 6–59 years 60+ years
8 weeks 3 4 6 1
8 weeks–1 year 1 3 11 3 The solutions used were as follows:
1–2 years 0 2 20 5
2+ years 0 3 19 6 N
Regarding the duration of operation, Kontny39 did not
observe any significant difference in infection rates, which
agrees with our study, where length of surgery had no
significant effect. Several reports identified perioperative
airborne contamination as the main source of infection,
particularly in procedures that included the insertion of a
prosthetic device.28 40 41 In one series there was a twofold
difference in infection complications between different
surgical teams (6–11.7%).28 Thus, aseptic technique appeared
to be a significant factor influencing the shunt infection rate.
We agree with Welch12 that shunt infection is a potentially
preventable complication. Odio et al25 found a median time
for postoperative infection of 8 days, whereas Mazza et al36
found the highest rate of infection at 15–28 days after shunt
operation. Hence, both of these studies confirm that infection
is temporally closely related to surgery. A similar report was
presented by George et al,1 who found that the experience of
the surgeon was the single most important factor in the
reduction of shunt infection rates, which is in accordance
with our study. Venes,42 and McCarthy and Wenzel43 also
placed particular emphasis on surgical technique in the
control of infection.
Choux et al44 claimed different results in two different
series conducted over different time periods. In the first series
(1978 to 1982), they demonstrated a rate of shunt infection
of 15.56%. In 1983 they introduced a protocol with stringent
technical perioperative guidelines, including vigorous asepsis
and limited personnel in the operation theatre. This resulted
in an infection rate of 0.33% in the second series. The only
difference in the two series was a change in operative
practice. All remaining parameters such as age, gender,
pathology, type of shunt, shunt material, surgeon, and
number of revisions caused no significant differences.
Choux et al stated that it was possible to reach a nearly zero
shunt infection rate.
We have demonstrated that, with careful aseptic and
antiseptic surgical technique and prophylactic antimicrobials,
it is possible virtually to eliminate shunt infections. It is
impossible to say which component of this approach is most
important: the rigid aseptic technique, the liberal use of
BetadineH, the avoidance of haematomas, or the antimicro-
bial prophylaxis. If infection is multifactorial, then perhaps
all components of the approach act in concert.
CONCLUSION
Shunt infection rates can be reduced or virtually eliminated
by strict adherence to the following simple surgical princi-
ples: asepsis, antisepsis, antimicrobial therapy, and the
avoidance of haematomas.
.....................
Authors’ affiliations
M S Choksey, I A Malik, Department of Neurosurgery, University
Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
APPENDIX
The operating theatre was a standard theatre as found in
most NHS hospitals, measuring 6.5 metres square and not
equipped with a laminar flow hood. The air was subject to 20
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Choksey, Malik
changes per hour. The theatre was part of a suite of four,
which was monitored continuously at a central console. Air
flow and filter alarms were in place, and the filters and plant
were checked every day in accordance with standard
operating theatre practice in the United Kingdom.
BetadineH antiseptic solution (Seton Healthcare Group)
containing povidone-iodine 10% w/v
N BetadineH alcoholic solution (Seton Healthcare Group)
containing povidone-iodine 10% w/v
N BetadineH Surgical Scrub (Seton Healthcare Group)
containing povidone-iodine 7.5% w/v
N BetadineH dry powder spray (Seton Healthcare Group)
containing povidone-iodine USP 2.5% w/v
N Chlorhexidine and cetrimide solution (MIZA Phar-
maceuticals UK) containing 0.25% chlorhexidine gluco-
nate solution 20% BP and 1.25% strong cetrimide solution
40%BP in purified water
N IobanH iodine impregnated transparent dressings (3M).
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