Original Article
Decreasing External Ventricular Drain Infection Rates in the Neurocritical Care Unit:
12-Year Longitudinal Experience at a Single Institution
Konrad W. Walek1, Owen P. Leary1, Rahul Sastry1, Wael F. Asaad1,3,4, Joan M. Walsh5, Leonard Mermel2,6,7
- OBJECTIVE: External ventricular drain (EVD) placement
is a common neurosurgical procedure, and EVD-related
infection is a significant complication. We examined the
effect of infection control protocol changes on EVD-related
infection incidence.
- METHODS: Changes in EVD placement protocol and
incidence density of infections after implementation of
protocol changes in the neurocritical care unit were
tracked from 2007 to 2019. EVD infections were defined
using a modified U.S. Centers for Disease Control and
Prevention National Healthcare Safety Network surveil-
lance definition of meningitis/ventriculitis for patients with
EVDs in situ for at least 2 days confirmed by positive cul-
ture. Contribution of protocol changes to EVD infection risk
was assessed via multivariate regression.
- RESULTS: Fifteen major changes in EVD protocol were
associated with a reduction in infections from 6.7 to 2.0 per
1000 EVD days (95% confidence interval [CI], 4.1e5.3;
P < 0.001). Gram-positive bacterial infection incidence
decreased from 4.8 to 1.7 per 1000 EVD days (95% CI, 2.3e
3.9; P ¼ 0.00882) and gram-negative infection incidence
decreased from 1.9 to 0.5 per 1000 EVD days (95% CI, 0.6e
2.3; P [ 0.0303). Of all protocol changes since 2007, the
largest reduction in incidence was 3.9 infections per 1000
Key words
- Catheter
- Central nervous system infection
- External ventricular catheter
- Nosocomial infection
- Ventriculitis
Abbreviations and Acronyms
4Q: 4 quarter
CDC: Centers for Disease Control and Prevention
CI: Confidence interval
CSF: Cerebrospinal fluid
EVD: External ventricular drain
H: Half-year
ICC: Infection control committee
NCCU: Neurocritical care unit
OR: Operating room
WORLD NEUROSURGERY 150: e89-e101, JUNE 2021
days (95% CI, 0.50e7.30; P [ 0.011), associated with
combined standardization of reduced EVD sampling fre-
quency, cutaneous antisepsis with alcoholic chlorhexidine
before EVD placement, and use of a subcutaneous
tunneling technique during EVD insertion.
- CONCLUSIONS: The most significant reduction in EVD
infections may be achieved through the combination of
reducing EVD sampling frequency and standardizing alco-
holic chlorhexidine cutaneous antisepsis and subcutane-
ous tunneling of the EVD catheter.
INTRODUCTION
E xternal ventricular drain (EVD) placement is a common
neurosurgical procedure. Indications include severe trau-
matic brain injury, acute hydrocephalus, intraventricular
hemorrhage, spontaneous subarachnoid hemorrhage, ven-
triculitis, shunt infection, and other need for urgent cerebrospinal
fluid (CSF) diversion. Infection is a serious potential complication
of EVD placement and increases the risk of poor neurosurgical
outcomes, obstruction of EVD flow, prolonged hospital length of
stay, systemic infection, and death.1 The incidence of EVD
infection reported in the literature ranges from 0% to 27% of
Q: Quarter-year
VP: Ventriculoperitoneal
From the Departments of 1Neurosurgery and 2Medicine, Warren Alpert Medical School of
Medicine of Brown University, Providence, Rhode Island; 3Department of Neuroscience,
Brown University, Providence, Rhode Island; and 4Norman Prince Neuroscience Institute,
5
Division of Critical Care, Department of Nursing, 6Department of Epidemiology and Infection
Control, and 7Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode
Island, USA
To whom correspondence should be addressed: Leonard Mermel, D.O., Sc.M.
[E-mail: LMermel@lifespan.org]
Citation: World Neurosurg. (2021) 150:e89-e101.
https://doi.org/10.1016/j.wneu.2021.02.087
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/ª 2021 The Authors. Published by Elsevier Inc. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
www.journals.elsevier.com/world-neurosurgery e89

KONRAD W. WALEK ET AL.
EVDs placed.2,3 There are several established risk factors
associated with EVD infections including extended EVD dwell
time, CSF leak, frequency of CSF sampling, frequency of EVD
manipulation, number of attempted EVD insertions, tract
hemorrhage at placement, and insufficient hair clipping.1,3-16
Some hypothesized risk factors for which there has been no
definitive evidence of association with EVD infection include age,
sex, Glasgow Coma Scale score, increased intracranial pressure at
time of EVD placement, systemic infection, presence of blood in
drainage system, use of periprocedural antibiotics, length of
hospital stay, involuntary EVD disconnection, placement by a ju-
nior surgeon, or coverage of the insertion site with a
dressing.1,3-6,8,10-15
Incomplete understanding of which factors contribute to EVD
infections and why has led to poorly standardized EVD infection
prevention strategies. Several institutions have shown a significant
reduction in EVD infections through implementation of protocols
for EVD insertion and maintenance, although specific protocol
changes implemented at each institution have varied.2,10,17,18 In
2007, the Department of Epidemiology & Infection Control at our
institution identified a high incidence density of EVD infections
(approximately 7e8/1000 EVD days) in the neurocritical care unit
(NCCU) involving both gram-positive and gram-negative patho-
gens. In response, an EVD infection control committee (ICC) was
formed with members from the departments of neurosurgery,
nursing, and neurocritical care. Since its inception, the committee
has recorded all EVD infections as they have occurred (e.g., date of
EVD insertion, patient location, EVD dwell time, and EVD in-
fections using criteria noted later), periodically recommended
changes in practice, and assessed the impact of these interventions
over time. Here, we summarize the protocol changes enacted since
2007 and the quarterly incidence of EVD infections.
METHODS
This is a retrospective analysis of prospectively collected data de-
tailing EVD infections in the NCCU of a 719-bed tertiary-care ac-
ademic medical center. The NCCU consisted of 12 beds from 2007
to April 2015, was expanded to 18 beds from April 2015, and was
moved to a new location within the institution in early 2018. EVD
infections were defined using a modified U.S. Centers for Disease
Control and Prevention (CDC) National Healthcare Safety Network
surveillance definition of meningitis/ventriculitis for patients with
EVDs in situ for at least 2 days, requiring positive CSF culture and
CSF glucose, protein, and cell counts consistent with infection for
diagnosis (CDC/National Healthcare Safety Network. Patient
Safety Component Manual, January 2020). EVD infection rates
were assessed over time and compared with timing of changes
made to EVD placement and/or maintenance policies. Written and
electronic records in the department of epidemiology and infec-
tion control, as well as personal records from the nursing quality
and safety manager for the NCCU, were reviewed to document the
timeline of recommendations from the local ICC, as well as
implementation of specific protocol changes.
Data Collection
All EVD infections per quarter are reported as a 4-quarter (4Q)
moving average of the previous 4Qs (total infections in past 4Q O
e90 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
total EVD days in past 4Q). This choice of metric was made to
minimize excessive variation (19 of the 50 quarters assessed had
0 infections) and is well suited for our analysis of the long-term
outcomes of protocol changes assumed to have instantaneous
time points of implementation. EVD days were calculated in terms
of point-prevalence at 9 PM daily. Data were analyzed from 2007 Q1
to 2019 Q2. These data result from quality assurance initiatives at
our institution as part of our standard infection control program;
no patient-specific data were reviewed or presented. Thus, this
study was exempt from institutional review board approval. For
this type of study, formal consent is not required. The Standards
for QUality Improvement Reporting Excellence (SQUIRE) guide-
lines were followed.19
Statistical Analysis
Multivariate logistic regression against both noninformative and
informative previous distributions was used to assess the strength
of effect of protocol changes on EVD infection rate, the primary
end point. Major protocol changes from Table 1 (EVD Infection
Control Bundle) were grouped into 15 bins by calendar year
quarter of implementation for analysis. We report the estimated
degree of contribution of the 15 protocol amendments to
changes in the EVD infection rate and 95% confidence intervals
(CIs). Statistical analysis was conducted with SPSS (IBM Corp.,
Armonk, New York, USA).
Current EVD Placement Procedure
At our institution, EVDs are routinely placed in the NCCU by
qualified neurosurgery residents or, occasionally, qualified
advanced practice practitioners under direct supervision of a
qualified resident. A resident or advanced practice practitioner is
deemed to be qualified after having successfully completed 5 EVD
placements under the observation and guidance of a more senior
resident or faculty. Starting in December 2017, the NCCU was
equipped with EVD insertion kits containing 1 Codman (Integra
LifeSciences, Princeton, New Jersey, USA) cranial access kit, 1
Codman ventriculostomy catheter, 1 Integra AccuDrain system
with access port, three 10-mL sterile saline flushes, four 3e0 nylon
sutures, one 3e0 monocryl suture, 1 electric clipper, 3 swab sticks
containing 2% chlorhexidine gluconate in 70% isopropyl alcohol
(ChloraPrep [Beckton Dickinson, Franklin Lakes, New Jersey,
USA]), 1 sterile gown, 2 pairs of sterile gloves, 1 hat, 1 face mask
with eye shield, 1 full body drape, 1 packet of bacitracin ointment,
and checklists for EVD insertion and the EVD infection control
bundle20,21 (Table 1 and Supplementary Tables 1 and 2). The
current procedure for EVD placement in the NCCU (as of 2019
Q3), which has resulted from the longitudinal institutional
experience shown in Figure 1, is described as follows.
Before the EVD insertion procedure begins, all doors (or cur-
tains in double-bed rooms) are closed and “Procedure in Progress”
signs are posted to minimize intraoperative entrance and egress.
All personnel entering or remaining in the room must wear a face
mask and cap. All tubing and cables are removed from the pro-
cedure field, and a mobile procedure table is positioned to
maintain a sterile field for the duration of the procedure. No
preprocedural prophylactic antibiotics are administered because
several studies1,22,23 have reported no benefit or minimal beneficial
effect of antibiotic prophylaxis on infection risk. Sedation and/or
 ORIGINAL ARTICLE
KONRAD W. WALEK ET AL. DECREASING EVD INFECTION RATES IN NCCU

Table 1. External Ventricular Drain Infection Control Bundle and Ventriculitis Review Form
EVD Infection Control Bundle Ventriculitis Review Form

EVD insertion protocol EVD insertion and maintenance

Hand hygiene with alcohol hand gel or chlorhexidine immediately before procedure Insertion bundle elements:
No preinsertion prophylactic antibiotics  Full drape over EVD insertion site?
Insertion site scrubbed with alcoholic chlorhexidine or povidone-iodine if patient is <2000 g  Hair clipped?
or allergic to chlorhexidine and allowed to dry (30 seconds scrub/30e60 seconds dry time)
Patient's head and body covered with full sterile drape  Chlorhexidine skin prep?
Sterile field maintained, including proceduralist (and direct assist) use of cap, mask, sterile Queries
gown and gloves, eye protection
All personnel entering or remaining in room must wear mask and cap Number of attempts at EVD insertion?
Only necessary personnel should enter or remain in room Number of times patient transported to the OR, general radiology, CT
imaging, or other areas outside of the intensive care unit?
Maintain closed door (and curtain for double-bed rooms) during procedure, place “Procedure Did patient have surgery/procedure (OR or patient care unit)?
in Progress” alert outside room
Aseptic technique used for connection of transducer (if required) Was it an EV shunt?
Catheter is tunneled under skin and secured in a coiled pattern with sutures Was EVD placed before infection?
Blood is cleansed from insertion site and alcoholic chlorhexidine applied; site is left open Did EVD become disconnected?
without gauze or occlusive dressing
No postinsertion prophylactic antibiotic Was EVD flushed or accessed before infection?
Antibiotic-impregnated EVD is to be used in patients for whom a ventriculoperitoneal shunt Was site care completed every 8 hours per protocol?
or EVD was removed because of proven or suspected infection
Maintenance: Site care Was chlorhexidine bathing done daily?
Hand hygiene immediately before procedure
Don mask and sterile gloves before performing site care
Gentle 30-second alcoholic chlorhexidine scrub to EVD catheter insertion site and
surrounding 50.8 mm (2 in) of skin every 8 hours (use povidone iodine if chlorhexidine
allergy)
EVD insertion site without dressing unless oozing from site in which case cover with 2  2
gauze dressing and occlusive dressing over gauze dressing
Maintenance: Changing collection reservoir
Hand hygiene immediately before procedure
Don clean gloves, cleanse Luer lock connection between drip chamber and collection
reservoir with povidone-iodine or alcoholic chlorhexidine; remove gloves
Hand hygiene, don mask and sterile gloves
Disconnect full collection reservoir at Luer lock connection; aseptically attach new collection
reservoir; discard old collection reservoir
Maintenance: Unintended disconnection
Hand hygiene immediately before procedure
Cover end of drain and clamp with Kelly clamp to prevent cerebrospinal fluid drainage
Do not reconnect old drainage system

EV, extraventricular; EVD, external ventricular drain; CT, computed tomography; OR, operating room.

analgesia are administered at the discretion of the proceduralist. per the proceduralist's discretion. A full body drape is used for
Because no specific area or dimension of hair to be clipped is the procedure. Once the patient is draped, the insertion site is
stipulated in our institutional bundle, hair clipping is performed marked, cleansed for 30 seconds, and allowed to dry for 3

WORLD NEUROSURGERY 150: e89-e101, JUNE 2021 www.journals.elsevier.com/world-neurosurgery e91


KONRAD W. WALEK ET AL.
Figure 1. Neurocritical care unit (NCCU) external ventricular drain (EVD)
infections per 1000 EVD days. The 4-quarter moving average infection
rate decreased from an average of 6.68 to 1.98/1000 EVD days (95%
confidence interval, 4.09e5.31; P < 0.001) when comparing 2007
H1e2009 H1 with 2017 H1e2019 H1. The mean incidence density of
EVD infections from 2007 H1 to 2019 H1 was 3.41/1000 EVD days.
minutes. Local anesthesia (lidocaine HCl and epinephrine
1:200,000) is administered to the scalp. Hand hygiene is
performed immediately before gloving for the procedure. The
proceduralist placing the EVD then dons a sterile gown and a
pair of sterile gloves. The scalp is incised and a burr hole is
created through the skull with a manual drill at the proper
anatomic location (typically the Kocher point). A none
antimicrobial-impregnated Codman EDS 335-cm clear ventricular
CSF catheter is passed into the ventricular system and tunneled
approximately 5 cm subcutaneously. Antimicrobial-impregnated
EVD catheters (Bactiseal, Dorchester, Massachusetts, USA) are
used only in patients for whom a ventriculoperitoneal (VP) shunt
or EVD was removed because of suspected or proven infection, or
for whom ventriculitis or meningitis is the indication for EVD
placement. A nylon stitch is placed in the scalp to secure the
placement of the EVD and flow of CSF is confirmed. The incision
is closed and the catheter secured to the scalp using nylon sutures.
A drainage system is connected using a sterile technique. Blood is
cleansed from the insertion site and alcoholic chlorhexidine is
again applied.
After EVD placement, routine maintenance includes site care,
change of collection reservoir when filled to capacity, and manage-
ment of unintended disconnection. All maintenance procedures are
performed after proper hand hygiene and donning sterile gloves. The
EVD site is cleansed with alcoholic chlorhexidine for 30 seconds at
e92 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
Major protocol changes are annotated above at their corresponding
points of implementation. EVD days per half-year are graphed on the
horizontal axis. CoNS, coagulase-negative staphylococci; CSF,
cerebrospinal fluid; H1, year first half, January 1eJune 30; min,
minimum; MSSA, methicillin-susceptible Staphylococcus aureus; OR,
operating room; d/c, discontinue.
least once every 8 hours.20,21 The site is not covered with a gauze or
occlusive dressing unless oozing from the site. If an EVD
replacement is required, it is typically conducted at the bedside in
the NCCU. Consistent with the 2016 recommendations of the
Neurocritical Care Society, no prophylactic antibiotics are
administered while the EVD is in situ and the EVD is removed and
the wound is sutured as soon as the EVD is no longer clinically
indicated.1 In the event of an infection after EVD placement, a
ventriculitis event review form is completed (Supplementary Table 3).
RESULTS
Observations of Infection Trends
Of the 50 quarters assessed, there were 19 quarters without an EVD
infection, 21 with 1 infection, 7 with 2 infections, and 3 with 3
infections. Of the 19 quarters without an EVD infection, 12
occurred in 2013 or later, and there was a 5-quarter period without
an EVD infection from 2014 Q4 until 2015 Q4. The average number
of infections per quarter for 2007e2012 was 1.08, whereas the
average number of infections per quarter was 0.60 for 2013e2019.
Incidence Density Analysis
The mean infection rate across all quarters (2007e2019) was 3.41/
1000 EVD days. The initial incidence density of EVD infections was
7.5/1000 EVD days in 2007 Q1 and reached a peak of 8.0 in 2008

KONRAD W. WALEK ET AL.
Figure 2. Multivariate regression coefficients of individual protocol
changes. Coefficients graphed as 95% confidence interval of the estimated
change in incidence density of external ventricular drain (EVD) infections for
protocol changes, grouped based on similar times of implementation.
Q4. The mean incidence density of infections in the first 2.5 years
(2007 H1e2009 H1, where H1 ¼ Q1þQ2 and H2 ¼ Q3þQ4) was
6.68/1000 EVD days and 1.98/1000 EVD days in the most recent 2.5
years (2017 H1e2019 H1). Thus, these protocol interventions are
correlated with a net estimated reduction of 4.70 EVD infections/
1000 EVD days (95% CI, 4.09e5.31; P < 0.001) from 2007 H1 to
2019 H1.
The mean incidence density of gram-positive bacterial in-
fections was 4.77/1000 EVD days from 2007 H1 to 2009 H1 and
decreased to 1.70/1000 EVD days from 2017 H1 to 2019 H1, an
estimated reduction of 3.07/1000 EVD days (95% CI, 2.27e3.87;
P ¼ 0.00882; Supplementary Figure 1). The most common gram-
positive organisms were coagulase-negative staphylococci and
Staphylococcus aureus, accounting for 17 of 33 cultured organisms
(Table 1 Ventriculitis Review Form and Supplementary Table 4). There
was a period without any gram-negative EVD infections from 2014
Q4 to 2018 Q1. From 2007 H1 to 2009 H1, there were 4 gram-
negative EVD infections, compared with 5 gram-negative in-
fections from 2009 H1 to 2019 H1. The mean incidence density of
gram-negative bacterial infections was 1.90/1000 EVD days from
2007 H1 to 2009 H1 and decreased to 0.53/1000 EVD days from
2017 H1 to 2019 H1, an estimated reduction of 1.47/1000 EVD days
(95% CI, 0.61e2.33; P ¼ 0.0303; Supplementary Figure 1). The
most common gram-negative organisms were Enterobacter aero-
genes and E. cloacae (Table 1 Ventriculitis Review Form and
Supplementary Table 4).
Regression analysis demonstrated that the combined protocol
change of reducing EVD reservoir culturing to 3 times weekly,
using alcoholic chlorhexidine for preparing the EVD insertion site,
and standardized coiled-catheter tunneling technique imple-
mented in 2008 Q3 achieved the strongest independent effect per
our criteria, with an estimated reduction of 3.9 infections per 1000
EVD days (95% CI, 0.50e7.30; P ¼ 0.011; Figure 2). Reduction of
culture frequency of EVD reservoir fluid from 3 times weekly to 2
times weekly was nonsignificantly associated with an additional
WORLD NEUROSURGERY 150: e89-e101, JUNE 2021
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
Statistical significance denoted with *. See Supplementary Table 3 for
detailed confidence intervals and P values. CSF, cerebrospinal fluid; NCCU,
neurocritical care unit; OR, operating room.
expected decrease of 3.1 infections per 1000 EVD days (95% CI,
e6.5 to 0.33; P ¼ 0.0957). Use of a chlorhexidine dressing
(Biopatch; Johnson & Johnson, New Brunswick, New Jersey,
USA) at the insertion site, discontinuation of all routine
antibiotic prophylaxis, and discontinuation of routine collection
of EVD reservoir fluid for culture, collectively trended toward an
expected decrease of 2.2 infections per 1000 EVD days (95% CI,
e4.5 to 0.20; P ¼ 0.0895).
Several other protocol changes showed a nonzero effect on
infection rate but did not reach our criteria for statistical sig-
nificance. Limiting extraneous personnel in the room during
EVD insertion showed a nonsignificant decrease of 0.83 in-
fections per 1000 EVD days (95% CI, e2.6 to 0.89; P ¼ 0.296).
Implementing use of sterile gloves for all procedures that involve
caring for the EVD site, implementing EVD site cleansing with
alcoholic chlorhexidine every 8 hours, and discontinuing chlor-
hexidine (Biopatch) dressing use were collectively associated
with a nonsignificant decrease of 1.4 infections per 1000 days
(95% CI, e3.9 to 1.2; P ¼ 0.269). These 3 protocol changes were
implemented in 2013. Obtaining daily EVD reservoir fluid cul-
tures and use of a standard EVD kit containing all necessary
components revealed nonsignificant increases of 2.1 (95% CI,
e2.0 to 6.3; P ¼ 0.244) and 1.3 (95% CI, e1.0 to 3.6; P ¼ 0.222)
infections per 1000 EVD days, respectively. In our model, use of
a standardized EVD checklist, use of wide hair clipping, use of a
lateral (vs. sagittal) incision, longer subcutaneous tunneling of
the EVD, performing all EVD replacements in the operating
room (OR), performing standardized EVD site assessments at
least every 4 hours, upgrading equipment from Codman EDS3 to
Integra AccuDrain, standardizing practice for managing leakage
around insertion site, accessing the EVD, /managing dis-
connecting drainage, use of an EVD infection prevention
checklist placed in all EVD kits, and use of electronic EVD order
sets or ventriculitis event review forms did not have a notable
effect on risk of infection (P > 0.3).
www.journals.elsevier.com/world-neurosurgery e93

KONRAD W. WALEK ET AL.
DISCUSSION
Recent attempts to standardize recommendations for EVD infection
prevention have included findings from meta-analyses of EVD inser-
tion and various maintenance techniques.1,24 Several
recommendations for best practice have been identified, including
weaning and removing the EVD as soon as no longer clinically
indicated, avoiding routine CSF sampling or changes in catheter
sites, and cleansing the insertion site with an antiseptic agent.1 Many
of these recommendations were implemented at our institution well
before the first of these recent reports was published in 2016. Several
recommendations, notably standardization of cutaneous antisepsis
and tunneling of EVD, that were implemented more than a decade
ago based on emerging evidence have achieved literature consensus
as standard of care.2,3,7,25-29 Our cumulative protocol changes
attempted to systematically address all modifiable risk factors for in-
fections identified through a multidisciplinary infection control pro-
gram, and our analysis identified reduced risk of EVD infections after
minimizing EVD manipulation, eliminating routine antibiotic pro-
phylaxis, and eliminating routine surveillance CSF sampling, consis-
tent with previous studies.1,24,30-32 Our findings suggest that
standardization across these protocol areas may cumulatively reduce
overall infection rate over time.
The factors most strongly associated with lowering our EVD
infection rate were reduction in the frequency of routine sampling
from the EVD collection reservoir for culture, cutaneous antisepsis
with alcoholic chlorhexidine, and introduction of a subcutaneous
catheter tunneling technique. These interventions were associated
with the largest absolute reduction in infection incidence density.
The interventions implemented in 2013 (implementation of sterile
gloves, site cleaning with chlorhexidine gluconate every 8 hours,
and discontinuing dressing use), were collectively associated with
the second largest absolute reduction in the 4Q moving average
infection rate. Limiting extra personnel in the room during EVD
insertion, use of sterile gloves for all procedures, cleansing the
EVD insertion site with alcoholic chlorhexidine every 8 hours, and
discontinuing use of the chlorhexidine dressing were associated
with nonsignificant reductions in the EVD infection rate. These
findings provide evidence for the relative effect of different
infection control measures, although these analyses are notably
limited by inability to account for the order in which individual
measures were implemented. Furthermore, our data showed an
unexplained increase in infection rate after the implementation of
standardized EVD kit use, a protocol change that was expected to
reduce infection rates by ensuring that all materials for sterile
placement were readily accessible. Although it is possible that
poor initial standardization of preparation and/or use of these kits
contributed to this result, this may also be a chance finding given
that the absolute number of infections was relatively low at the
time of this intervention (2017 H2). The decreased infection rate
that we observed with decreased CSF sampling frequency is
consistent with several studies that showed reduced infections
when EVD manipulation was minimized and sampling was per-
formed only for indications of new onset of fever, leukocytosis
found on routine complete blood counts, neurologic deterioration,
assessment of CSF protein levels in consideration of upcoming VP
shunt, or other suspicion for infection.1,6,33
e94 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
Infection control interventions implemented at other institutions
have also shown decreases in infection rates. In one study,2 a strict
protocol for inserting EVDs only in the OR was implemented, using
prophylactic antibiotics, ensuring that catheters are subcutaneously
tunneled at least 10 cm, omitting daily sampling, and avoiding
routine catheter changes without clinical indication. That study
observed an associated reduction in the EVD infection rate from
27% to 12%. EVD placement outside the OR is necessary in many
settings because of resource availability and urgent need for
intervention. In a more recent study, implementing a best-
practice protocol stressing hand hygiene before EVD insertion,
prophylactic antibiotics, sterile glove changes between preparation/
draping/procedure, hair removal by clipping, cutaneous use of
povacrylex/isopropyl alcohol, full body and head draping, full sur-
gical attire for surgeon and bedside providers, antimicrobial-
impregnated catheter use, and a checklist of critical components
was associated with a reduction in EVD infections from 9.2% to
0.5%.17 Other investigators using a similar protocol reported an
associated reduction in the EVD infection rate from 9.2% to less
than 1% over a 5-year period.18
Our multidisciplinary EVD ICC recommendations on several
specific interventions were made based on available evidence at
the time, with a few exceptions. For example, there has been
considerable debate surrounding the benefits of antimicrobial-
impregnated EVDs.1,34,35 Some studies10,13,17,36,37 have noted a
reduction in EVD infections with antimicrobial EVDs, whereas
others36,38,39 have found no significant benefit. Furthermore,
concerns have been raised over the possible neurotoxicity of
silver ions36,40 and the potential for an increased risk of
infections with antibiotic-resistant pathogens with the use of
antimicrobial EVDs.36 The most recent meta-analysis of 5242
cases23 found a reduction in EVD infection risk with the use of
systemic antibiotics and antimicrobial EVDs, but less certainty
regarding the impact of reduced infection risk on morbidity,
mortality, health care costs, or length of stay.
Our EVD ICC has considered standardizing the use of antimi-
crobial EVDs. Although the 2016 Neurocritical Care Society guide-
lines advocate for the use of antimicrobial-impregnated EVDs, there
is also a costebenefit argument to be made for using these more
expensive devices.1 In light of this situation, our institution's policy
is that antimicrobial EVDs are recommended for use only in patients
for whom a VP shunt or EVD was removed because of proven or
suspected meningitis and/or ventriculitis.1,34,35 Although many of
the measures that we implemented did not independently achieve
statistical significance, the collective suite of measures applied
decreased the infection rates more substantially over our 12-year
study period than any individual measure. Our institution ach-
ieved infection rates similar to, and in some instances lower than,
those achieved by institutions that implemented antimicrobial
EVDs as standard of care,10,13,17,23,36-39 which we attribute to our
EVD ICC's recommended policy of cutaneous antisepsis with
alcoholic chlorhexidine to the EVD insertion site24 and
discontinuation of prophylactic postprocedural systemic
antibiotics.2,7,10,17,30-32,37,41-45 It is of course possible that our
infection rate can be further decreased with the standardization of
antimicrobial EVDs in the future.
 ORIGINAL ARTICLE
KONRAD W. WALEK ET AL. DECREASING EVD INFECTION RATES IN NCCU

Study Limitations
We did not monitor compliance with the interventions, excluding
hand hygiene compliance; however, because most interventions
consisted of recommending institutional standardization of key
protocol areas, it seems safe to assume that standardization with
respect to each protocol area of focus increased immediately after
the corresponding recommendation. We did not monitor the inci-
dence density of EVD infections in other units such as our trauma
intensive care unit or pediatric intensive care unit. Although most
EVDs in our hospital are managed in our NCCU, we cannot be
certain that the reduction in EVD infections observed in the NCCU
occurred in these other patient care units. In addition, diagnosis of
an EVD infection is complicated by the fact that infection may occur
with negative CSF cultures, such as sampling CSF after inititation of
antibiotic therapy. Our institution uses a modified CDC National
Healthcare Safety Network definition of ventriculitis/meningitis, in
which we have required a positive CSF culture. Surveillance for
possible culture-negative EVD infections was not carried out by the
Department of Epidemiology and Infection Control over the study
period and therefore cannot be reported. Lack of reported culture-
negative infections raises the question that such infections may
have still occurred, introducing possible selection bias and thus our
true EVD infection rate may be higher than reported herein. How-
ever, use of a consistent definition for EVD infections has allowed us
to assess infection rates over time, under different protocol condi-
tions. As a single-institutional study, the applicability of our results
to other institutions may be influenced by institution-specific biases
(e.g., teaching hospital status and local patient demographics),
although our results seem consistent with literature from other
institutions.
CONCLUSIONS
Through the implementation of continuous evidence-based im-
provements to our EVD standard of practice from 2007 to 2019,
our institution has achieved a significant reduction in the rate of
EVD infections in our NCCU population. The most effective pro-
tocol changes have been elimination of routine EVD surveillance
cultures, standardized use of alcoholic chlorhexidine for cuta-
neous antisepsis, and standardized use of a modified tunneling
technique with coiling of the catheter under the skin. We observed
a reduction in EVD infections per 1000 EVD days from 6.68 (2007e
2009) to 1.98 (2017e2019), with a relative risk reduction of
approximately 70%. Based on our experience, we believe that an
institutional EVD ICC that draws from multiple pools of relevant
experience and meets regularly to recommend possible in-
terventions is important in implementation of best practices
aimed at reducing risk of EVD infections.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Konrad W. Walek: Conceptualization, Methodology, Formal
analysis, Investigation, Data curation, Writing - original draft,
Writing - review & editing, Visualization. Owen P. Leary:
Conceptualization, Methodology, Software, Investigation, Data
curation, Writing - review & editing. Rahul Sastry: Conceptuali-
zation, Methodology, Data curation, Writing - review & editing.
Wael F. Asaad: Validation, Resources, Writing - review & editing,
Supervision. Joan M. Walsh: Conceptualization, Methodology,
Validation, Writing - review & editing. Leonard Mermel:
Conceptualization, Methodology, Validation, Resources, Writing -
review & editing, Supervision, Project administration.
ACKNOWLEDGMENTS
The authors thank the Rhode Island Hospital infection control
staff for their thoughtful assistance in mitigating EVD infection
risk and managing data related to this project.

REFERENCES
1. Fried HI, Nathan BR, Rowe AS, et al. The inser-
tion and management of external ventricular
drains: an evidence-based consensus statement.
Neurocrit Care. 2016;24:61-81.
2. Dasic D, Hanna SJ, Bojanic S, Kerr RSC. External
ventricular drain infection: the effect of a strict
protocol on infection rates and a review of the
literature. Br J Neurosurg. 2006;20:296-300.
3. Lozier AP, Sciacca RR, Romagnoli MF,
Connolly ES Jr. Ventriculostomy-related in-
fections: a critical review of the literature. Neuro-
surgery. 2002;51:170-182.
4. Flint AC, Toossi S, Chan SL, Rao VA, Sheridan W.
A simple infection control protocol durably re-
duces external ventricular drain infections to near-
zero levels. World Neurosurg. 2017;99:518-523.
5. Keong NCH, Bulters DO, Richards HK, et al. The
SILVER (Silver Impregnated Line Versus EVD
Randomized Trial). Neurosurgery. 2012;71:394-404.
6. Hader WJ, Steinbok P. The value of routine cul-
tures of the cerebrospinal fluid in patients with
external ventricular drains. Neurosurgery. 2000;46:
1149-1155.
7. Hepburn-Smith M, Dynkevich I, Spektor M,
Lord A, Czeisler B, Lewis A. Establishment of an
external ventricular drain best practice guideline.
J Neurosci Nurs. 2016;48:54-65.
8. Hoefnagel D, Dammers R, TerLaak-Poort MP,
Avezaat CJJ. Risk factors for infections related to
external ventricular drainage. Acta Neurochir (Wien).
2008;150:209-214.
9. Kim J, Lee J, Feng R, et al. Ventricular Catheter
Tract Hemorrhage as a Risk Factor for
Ventriculostomy-Related Infection. Operative
Neurosurgery. 2020;18:69-74.
10. Korinek A-M, Reina M, Boch AL, Rivera AO, De
Bels D, Puybasset L. Prevention of external ven-
tricular drain-related ventriculitis. Acta Neurochir
(Wien). 2004;147:39-46.
11. Lyke KE, Obasanjo OO, Williams MA, O’Brien M,
Chotani R, Perl TM. Ventriculitis complicating use
of intraventricular catheters in adult neurosurgical
patients. Clin Infect Dis. 2001;33:2028-2033.
12. Mayhall CG, Archer NH, Lamb VA, et al. Ven-
triculostomy-related infections. N Engl Med. 1984;
310:553-559.
13. Moussa WMM, Mohamed MAA. Efficacy of post-
operative antibiotic injection in and around ven-
triculoperitoneal shunt in reduction of shunt
infection: a randomized controlled trial. Clin Neurol
Neurosurg. 2016;143:144-149.
14. Trick WE, Kioski CM, Howard KM, et al.
Outbreak of Pseudomonas aeruginosa ventriculitis
among patients in a neurosurgical intensive care
unit. Infect Control Hosp Epidemiol. 2000;21:204-208.
15. Bota DP, Lefranc F, Vilallobos HR, Brimioulle S,
Vincent J-L. Ventriculostomy-related infections in
critically ill patients: a 6-year experience.
J Neurosurg. 2005;103:468-472.
16. Chrintz H, Vibits H, Cordtz TO, Harreby JS,
Waaddegaard P, Larsen SO. Need for surgical
wound dressing. Br J Surg. 1989;76:204-205.
17. Kubilay Z, Amini S, Fauerbach LL, Archibald L,
Friedman WA, Layon AJ. Decreasing ventricular
infections through the use of a ventriculostomy
placement bundle: experience at a single institu-
tion. J Neurosurg. 2013;118:514-520.

WORLD NEUROSURGERY 150: e89-e101, JUNE 2021 www.journals.elsevier.com/world-neurosurgery e95


KONRAD W. WALEK ET AL.
18. Rahman M, Whiting JH, Fauerbach LL, Archibald L,
Friedman WA. Reducing ventriculostomy-related
infections to near zero: the eliminating ven-
triculostomy infection study. Jt Comm J Qual Patient
Saf. 2012;38:459-464.
19. Ogrinc G, Davies L, Goodman D, Batalden P,
Davidoff F, Stevens D. SQUIRE 2.0 (Standards for
QUality Improvement Reporting Excellence):
revised publication guidelines from a detailed
consensus process. BMJ Qual Saf. 2015;25:986-992.
Table 1.
20. Chatzi M, Karvouniaris M, Makris D, et al. Bundle
of measures for external cerebral ventricular
drainage-associated ventriculitis. Crit Care Med.
2014;42:66-73.
21. Lele AV, Hoefnagel AL, Schloemerkemper N,
et al. Perioperative management of adult patients
with external ventricular and lumbar drains.
J Neurosurg Anesthesiol. 2017;29:191-210.
22. May AK, Fleming SB, Carpenter RO, et al. Influ-
ence of broad-spectrum antibiotic prophylaxis on
intracranial pressure monitor infections and sub-
sequent infectious complications in head-injured
patients. Surg Infect. 2006;7:409-417.
23. Sheppard JP, Ong V, Lagman C, et al. Systemic
antimicrobial prophylaxis and antimicrobial-
coated external ventricular drain catheters for
preventing ventriculostomy-related infections: a
meta-analysis of 5242 cases. Neurosurgery. 2020;86:
19-29.
24. Lele AV, Mills B, Qiu Q, et al. International
multicenter survey of perioperative management
of external ventricular drains. J Neurosurg Anes-
thesiol. 2020;32:132-139.
25. Khanna RK, Rosenblum ML, Rock JP, Malik GM.
Prolonged external ventricular drainage with
percutaneous long-tunnel ventriculostomies.
J Neurosurg. 1995;83:791-794.
26. Collins CDE, Hartley JC, Chakraborty A,
Thompson DNP. Long subcutaneous tunnelling
reduces infection rates in paediatric external
ventricular drains. Childs Nerv Syst. 2014;30:
1671-1678.
27. Zhou Y-J, Wu J-N, Chen L-J, Zhao H-Y. Compar-
ison of infection rate with tunneled vs standard
external ventricular drainage: a prospective, ran-
domized controlled trial. Clin Neurol Neurosurg.
2019;184:105416.
e96 www.SCIENCEDIRECT.com
DECREASING EVD INFECTION RATES IN NCCU
28. Dey M, Jaffe J, Stadnik A, Awad IA. External
ventricular drainage for intraventricular hemor-
rhage. Curr Neurol Neurosci Rep. 2011;12:24-33.
29. Leung GKK, Ng KB, Taw BBT, Fan YW. Extended
subcutaneous tunnelling technique for external
ventricular drainage. Br J Neurosurg. 2007;21:
359-364.
30. Prabhu VC, Kaufman HH, Voelker JL, et al. Pro-
phylactic antibiotics with intracranial pressure
monitors and external ventricular drains: a review
of the evidence. Surg Neurol. 1999;52:226-237.
31. Sonabend AM, Korenfeld Y, Crisman C,
Badjatia N, Mayer SA, Connolly ES Jr. Prevention
of ventriculostomy-related infections with pro-
phylactic antibiotics and antibiotic-coated external
ventricular drains: a systematic review. Neurosur-
gery. 2011;68:996-1005.
32. Wyler AR, Kelly WA. Use of antibiotics with
external ventriculostomies. J Neurosurg. 1972;37:
185-187.
33. Williams TA, Leslie GD, Dobb GJ, Roberts B, van
Heerden PV. Decrease in proven ventriculitis by
reducing the frequency of cerebrospinal fluid
sampling from extraventricular drains. J Neurosurg.
2011;115:1040-1046.
34. Scheithauer S, Burgel U, Ryang Y-M, et al. Pro-
spective surveillance of drain associated menin-
gitis/ventriculitis in a neurosurgery and
neurological intensive care unit. J Neurol Neurosurg
Psychiatry. 2009;80:1381-1385.
35. Humphreys H, Jenks PJ. Surveillance and man-
agement of ventriculitis following neurosurgery.
J Hosp Infect. 2015;89:281-286.
36. Wang X, Dong Y, Qi X-Q, Li Y-M, Huang C-G,
Hou L-J. Clinical review: efficacy of antimicrobial-
impregnated catheters in external ventricular
drainageea systematic review and meta-analysis.
Crit Care. 2013;17:234.
37. Zabramski JM, Whiting D, Darouiche RO, et al.
Efficacy of antimicrobial-impregnated external
ventricular drain catheters: a prospective, ran-
domized, controlled trial. J Neurosurg. 2003;98:
725-730.
38. Winkler KML, Woernle CM, Seule M, Held U,
Bernays RL, Keller E. Antibiotic-impregnated
versus silver-bearing external ventricular drainage
catheters: preliminary results in a randomized
controlled trial. Neurocritic Care. 2013;18:161-165.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087
ORIGINAL ARTICLE
39. Wong GKC, Ip M, Poon WS, Mak CWK, Ng RYT.
Antibiotics-impregnated ventricular catheter
versus systemic antibiotics for prevention of
nosocomial CSF and non-CSF infections: a pro-
spective randomised clinical trial. J Neurol Neuro-
surg Psychiatry. 2010;81:1064-1067.
40. Lansdown ABG. Critical observations on the
neurotoxicity of silver. Crit Rev Toxicol. 2007;37:
237-250.
41. Alleyne CH Jr, Hassan M, Zabramski JM. The ef-
ficacy and cost of prophylactic and periprocedural
antibiotics in patients with external ventricular
drains. Neurosurgery. 2000;47:1124-1129.
42. Aucoin PJ, Kotilainen HR, Gantz NM,
Davidson R, Kellogg P, Stone B. Intracranial
pressure monitors. Epidemiologic study of risk
factors and infections. Am J Med. 1986;80:369-376.
43. Blomstedt GC. Results of trimethoprim-
sulfamethoxazole prophylaxis in ventriculostomy
and shunting procedures. J Neurosurg. 1985;62:
694-697.
44. Leclair JM, Winston KR, Sullivan BF,
O’Connell JM, Harrington SM, Goldmann DA.
Effect of preoperative shampoos with chlorhexi-
dine or lodophor on emergence of resident scalp
flora in neurosurgery. Infect Control Hosp Epidemiol.
1988;9:8-12.
45. Poon WS, Ng S, Wai S. CSF Antibiotic prophylaxis
for neurosurgical patients with ventriculostomy: a
randomised study. In: Marmarou A, Bullock R,
Avezaat C, et al., eds. Intracranial Pressure and Neu-
romonitoring in Brain Injury. Vienna: Springer; 1998:
146-148.
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 26 November 2020; accepted 18 February 2021
Citation: World Neurosurg. (2021) 150:e89-e101.
https://doi.org/10.1016/j.wneu.2021.02.087
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/ª 2021 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

KONRAD W. WALEK ET AL.
SUPPLEMENTARY DATA
Supplementary Figure 1. Gram-positive bacterial
external ventricular drain (EVD) infections per 1000
EVD days. The mean incidence density of
gram-positive bacterial infections of 4.77/1000 EVD
days from 2007 H1 to 2009 H1 decreased to
1.70/1000 EVD days from 2017 H1 to 2019 H1
(reduction of 3.07c/1000 EVD days; 95% CI,
WORLD NEUROSURGERY 150: e89-e101, JUNE 2021
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
2.27e3.87; P ¼ 0.00882). The mean incidence density
of gram-negative bacterial infections of 1.90/1000 EVD
days from 2007 H1 to 2009 H1 decreased to
0.53/1000 EVD days from 2017 H1 to 2019 H1
(reduction of 1.47/1000 EVD days; 95% CI, 0.61e2.33;
P ¼ 0.0303). H1, year first half, January 1eJune 30;
H2, year second half, July 1eDecember 31.
www.journals.elsevier.com/world-neurosurgery e97

KONRAD W. WALEK ET AL.
Supplementary Table 1. Summary of Identified Failure Modes and Resulting Protocol Changes
Failure Mode
Nonstandard clipping procedure;
chlorhexidine dressing used over
insertion site (Biopatch)
Inconsistencies in EVD site care
EVDs left in place beyond period of
clinical indication
Inconsistencies in EVD site preparation
Consideration of using antimicrobial EVD
Oversampling of EVDs (daily)
No standard checklist for EVD placement
Nonstandard EVD placement
No standard protocol for duration of
dressing placement or timeline for
changing dressing
Oversampling of EVDs (3 weekly)
Oversampling of EVDs (2 weekly)
Setting (e.g., emergency department,
NCCU) for EVD placement not routinely
tracked
Excess traffic in/out of patient rooms
during EVD placement
No standard for frequency of assessing
EVD site
No formal written protocol available for
EVD care and dressing change policy
Sterile gloves not being used for EVD-
related procedures (except insertion)
Recalls issued on Codman EDS3 CSF
external drainage system
e98 www.SCIENCEDIRECT.com
Identified Concern/Impacts
Pre-2006 Poor adherence of dressing to scalp
2008 Q1 Increased risk of infection because of
possible insertion site contamination
2008 Q1 Possibly increased risk of infection
associated with prolonged EVD duration
2008 Q2 Increased risk of infection because of
possible insertion site contamination
2008 Q2 Possible increased risk of using
nonantimicrobial EVD
2008 Q2 Increased infection rate because of risk
of EVD contamination during sampling
2008 Q3 Inconsistencies in EVD placement
possibly leading to higher infection risk
2008 Q3 Inconsistencies in EVD placement
possibly leading to higher infection risk
2008 Q2 Possibly increased risk of infection due
to prolonged use
2008 Q3 Increased infection rate because of risk
of EVD contamination during sampling
2008 Q4 Increased infection rate because of risk
of EVD contamination during sampling
2008 Q3 Inability to identify potential
contamination sources without
documented placement setting
2010 Q2 Potential contamination of the sterile
field during insertion
2012 Q4 Potential delayed recognition of EVD
complications (e.g., leak) that risk
contamination
2010 Q2 Potential risk of contamination because
of nonstandard EVD care and
maintenance
2013 Q2 Potential contamination of EVD during
manipulation
2014 Q3 Potential contamination of EVD because
of faulty equipment
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
Solution (Protocol Change) Implemented
Surgical clippers for removing hair before 2006
EVD placement procedure
Ensure scrupulous EVD site care during 2008 Q1
and after insertion, including alcoholic
chlorhexidine (ChloraPrep) at least every
8 hours for all EVDs
Remove EVDs as soon as not absolutely 2008 Q3
indicated
Alcoholic chlorhexidine used for all EVD 2008 Q3
insertion site cutaneous antisepsis
Decision to continue use of 2008 Q3
nonantimicrobial EVD because
of concerns regarding increased risk of
antimicrobial resistance with routine use
Reduced culturing CSF from EVD 2008 Q3
drainage reservoirs to 3 times weekly
Checklist developed for standard EVD 2008 Q3
placement (Table 1 Ventriculitis Review
Form)
Standardized technique: tunneling, 2008 Q3
suturing, chlorhexidine dressing, coiling
catheter under dressing
If dressing dry and intact, then change at 2008 Q4
72 hours. Emphasis on not leaving
dressing wet. Use nonocclusive dressing
to redress insertion site
Reduced culturing CSF from EVD 2008 Q4
reservoirs to 2 times weekly
Reduced culturing CSF from EVD 2008 Q4
reservoirs to only when infection
suspected.
Discontinue all sampling in
asymptomatic patients
Routine documentation of EVD 2010 Q2
placement setting
Minimize extra personnel from entering 2010 Q3
room when an EVD is being inserted
EVD site assessed every 8 hours 2013 Q1
minimum, every 4 hours in ICU or with
pediatric patients
Development of protocols and 2013 Q3
implementation of formalized updated
EVD policy, including insertion, care,
maintenance, and removal
Use sterile gloves for any EVD 2013 Q3
manipulation
Switch from Codman EDS3 to Integra 2014 Q3
AccuDrain with longer tubing
Continues

KONRAD W. WALEK ET AL.
Supplementary Table 1. Continued
Failure Mode
No standard practice for accessing EVD
to obtain specimens or inject
medications
Lack of standard EVD insertion kit
Increase in number of infections after 5-
quarter EVD infection-free period
Inconsistencies noted in systematic
reporting of EVD infection cases
Unexpected increase in EVD infection
rate
No standard practice for managing leaks
around EVD insertion site
No standard practice to manage EVD
drainage tubing disconnection
EVD, external ventricular drain; Q, quarter; CSF, cerebrospinal fluid; NCCU, neurocritical care unit; ICU, intensive care unit.
WORLD NEUROSURGERY 150: e89-e101, JUNE 2021
Identified Concern/Impacts
2014 Q1 Potential contamination of EVD during
manipulation
2009 Q4 Equipment unavailability or omission
may delay procedure and/or increase risk
of contamination
2016 Q3 Cause unknown. Possible lack of
adherence to infection prevention
protocol
2017 Q4 Potential lack of critical information
about confirmed infection cases
2019 Q1 Cause unknown. Possible contribution of
nonstandard EVD flushing techniques or
drawing of surveillance cultures every 48
hours for persistently febrile patients
2014 Q1 Suturing EVD insertion CSF leak site vs.
replacing/removing EVD; best practice to
minimize contamination risk is unclear
2014 Q1 Potential contamination of EVD during
manipulation
www.journals.elsevier.com/world-neurosurgery
ORIGINAL ARTICLE
DECREASING EVD INFECTION RATES IN NCCU
Solution (Protocol Change) Implemented
Ensuring sampling of CSF is performed 2015 Q2
with sterile technique and only with
known leak or suspicion for CSF infection
Creation of a standard EVD insertion kit 2017 Q3
for NCCU, trauma ICU, pediatric ICU,
adult and pediatric emergency
departments, with all necessary
components
EVD infection prevention bundle, 2017 Q4
including protocols for insertion, site
care, and unintended disconnect, drafted
for inclusion with EVD kits
New electronic Ventriculitis Event 2018 Q2
Review Form implemented (Table 1)
Standard protocol developed for EVD 2019 Q2
flushing. Reduction of surveillance
culture frequency under consideration
If a single suture does not stop a CSF 2019 Q3
leak, the leakage is taken as a sign of
refractory high intracranial pressure and/
or EVD wean failure and the EVD is
either decreased to a lower pressure or
opened (if previously clamped)
Cleanse the proximal catheter with 2019 Q3
alcoholic chlorhexidine and, under sterile
conditions, attach a new sterile drainage
system to the previous site of
disconnection.
e99
 ORIGINAL ARTICLE
KONRAD W. WALEK ET AL. DECREASING EVD INFECTION RATES IN NCCU

Supplementary Table 2. Checklist for External Ventricular Drain

Insertion
Before Procedure: During Procedure:

Verified ID of patient? Use of hat, mask, sterile gown and

gloves, eye protection, maintain sterile
field?
Is the procedure elective/emergent? By physician?
Previously used site/new site? By assisting personnel?
Site of insertion marked? After procedure:
Briefing and time out? Connect to drainage apparatus with
aseptic technique?
Before the procedure, did the Number of attempts?
physician:
Cleanse hands immediately prior?
Use clippers to remove hair as
needed?
Cleanse insertion site with
alcoholic chlorhexidine and allow
to dry before proceeding?
Use large barrier drape around
insertion site?

Supplementary Table 3. Number of Neurocritical Care Unit External Ventricular Drain Infections by Pathogen (2007 H1e2019 H1)
Gram-Positive Bacteria Gram-Negative Bacteria Fungi

Coagulase-negative Staphylococcus 22 Enterobacter aerogenes 4 Candida albicans 1

methicillin-sensitive 18 Enterobacter cloacae 2 Candida parapsilosis 1
methicillin-resistant 4
Staphylococcus aureus 4 Stenotrophomonas maltophila 1
methicillin-resistant 3 Klebsiella oxytoca 1
methicillin-sensitive 1
Enterococcus faecalis 3 Klebsiella pneumoniae 1
Cutibacterium acnes 3 Citrobacter koseri 1
Enterococcus faecium 1 Pantoea agglomerans 1
Finegoldia magna 1 Serratia marcescens 1
Micrococcus luteus 1

e100 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2021.02.087

 ORIGINAL ARTICLE
KONRAD W. WALEK ET AL. DECREASING EVD INFECTION RATES IN NCCU

Supplementary Table 4. Estimated Impact of Infection Control Interventions

Estimated Change in
Infection Rate/1000 EVD Days
Intervention Period of Implementation (95% Confidence Interval) P

Culturing CSF from EVD reservoirs daily Start: 2007 Q1 D2.14 (e2.04 to 6.31) 0.768
End: 2008 Q2 (EVD sampling
frequency later further reduced)
Scrupulous site care during/after insertion Start: 2008 Q1 e0.44 (e2.96 to 2.08) 0.441
Removing EVDs when not indicated
Standard checklist for EVD Start: 2008 Q3 e0.15 (e3.24 to 2.93) 0.502
Reduction in EVD sampling frequency from daily to 3 weekly Start: 2008 Q3 (EVD sampling e3.91 (e7.30 to -0.52) 0.011
ChloraPrep before EVD. Tunneled EVD technique frequency later further reduced)
Reduction in EVD sampling frequency from 3 weekly to 2 weekly Start: 2008 Q4 e3.07 (e6.46 to 0.33) 0.096
End: 2008 Q4 (EVD sampling
frequency later further reduced)
Reduction in EVD sampling frequency from 2 weekly to only when infection Start: 2008 Q4 e2.16 (e4.52 to 0.20) 0.090
suspected
End of routine antibiotic prophylaxis while EVD in place
Wide hair clap, lateral incisions (vs. sagittal), longer catheter tunneling under skin. Start: 2008 Q4 e0.94 (e3.37 to 1.50) 0.343
All EVD replacements performed in operating room
Limit extra personnel entering room during EVD placement Start: 2010 Q3 e0.83 (e2.56 to 0.89) 0.296
Standardized assessing EVD site at least every 8 hours Start: 2013 Q3 e0.16 (e1.63 to 1.32) 0.474
Sterile gloves for any EVD manipulation. Cleansing EVD site with ChloraPrep at Start: 2013 Q3 e1.36 (e3.88 to 1.16) 0.269
least every 8 hours. No longer using Biopatch
Equipment upgrade from Codman EDS3 to Integra AccuDrain Start: 2014 Q3 e0.39 (e2.75 to 1.97) 0.446
Standardized practice for accessing EVD, managing CSF leakage, and discontinue Start: 2015 Q2 e0.35 (e2.66 to 1.97) 0.454
of drainage tubing
Standard EVD kit for neurocritical care unit with all necessary components Start: 2017 Q3 D1.29 (e1.03 to 3.60) 0.789
EVD infection prevention bundle included with all EVD kits Start: 2017 Q4 e0.95 (e4.04 to 2.13) 0.454
Electronic EVD order set implemented in Epic EMR Start: 2018 Q1 e0.44 (e3.53 to 2.64) 0.457
Electronic ventriculitis event review form implemented for reporting EVD infection Start: 2018 Q2 D0.30 (e2.22 to 2.82) 0.581
events

Bold values indicate multivariate regression coefficients of individual protocol changes.

CSF, cerebrospinal fluid; EVD, external ventricular drain; Q, quarter.

WORLD NEUROSURGERY 150: e89-e101, JUNE 2021 www.journals.elsevier.com/world-neurosurgery e101