Original Article

Cerebrospinal Fluid Infection Associated with Silver-Impregnated External Ventricular Drain Catheters Ross Atkinson1,2, Lubna Fikrey3, Anna Jones1, Catherine Pringle1, Hiren C. Patel1,2

- OBJECTIVE: Silver-impregnated external ventricular EVD insertion according to a set protocol. These data sug- drains (EVDs) have reduced the number of cases of ven- gest that targeting strategies to reduce Staphylococcus triculitis. Risk factors for developing ventriculitis associated species is important, and increased vigilance for an with plain EVD catheters have been well documented and increased incidence of gram-negative organisms is needed. incorporated into clinical practice, but risk factors in asso- Decreasing the need for EVD replacement is important in ciation with silver EVDs are unknown. Therefore, we sought reducing infection rates further. to determine the risk factors for developing ventriculitis in patients with a silver EVD. - METHODS: Prospectively collected data on consecutive patients undergoing insertion of a silver-impregnated EVD between October 2011 and September 2013 were analyzed. INTRODUCTION Cerebrospinal fluid (CSF) infection was defined as positive n external ventricular drain (EVD) is a medical device that CSF microbiologic culture. Univariate and multivariate is inserted into the ventricles of the brain that serves to regression was performed to identify independent risk A divert cerebrospinal fluid (CSF). Insertion of an EVD is a factors for CSF infection. common neurosurgical procedure performed to control elevated intracranial pressure, which is a frequent consequence of acute - RESULTS: There were 362 EVDs placed in 263 patients (142 brain injury caused by conditions such as subarachnoid hemor- women; median age 52 years; interquartile range, 40e62 rhage, intracerebral hemorrhage, tumor, or trauma (traumatic years). There were 15 infections (6.4 per 1000 days of EVD brain injury). Although placement of an EVD can be a lifesaving drainage) recorded. Gram-negative organisms (8 of 15) were procedure, it is associated with numerous risks, including infec- most commonly observed, although Staphylococcus was the tion. The reported incidence of CSF infections is approximately e 1-5 most common genus (7 of 15; 46%) identified. Univariate 0.8% 30%, and infection of the CSF (also referred to as ventriculitis or catheter-related infection) is associated with analysis indicated that patients requiring EVD replacement fi 6 < < signi cant morbidity and mortality. (P 0.0001), patients requiring bilateral EVDs (P 0.0001), Many previous reports have described and identified indepen- < and patients with a CSF leak (P 0.0001) were at increased dent risks for the development of EVD infections.6-9 Factors risk of infection. Only need for EVD replacement remained associated with an increased risk of EVD-related infection include significant on multivariate analysis (P < 0.0001, odds ratio [ increased indwelling duration, pathology (higher risk in patients 15.9, confidence interval [ 4.5e55.9). with spontaneous intracranial hemorrhage), tunneling of catheters <5 cm, CSF leak, concurrent systemic infection, increased CSF - CONCLUSIONS: We identified an infection rate of 5.2% in sampling frequency, and requirement for drain replacement.6-9 this large contemporary series of patients undergoing silver Factors associated with a reduction of infection rates include the

Key words From the 1Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, United 2 - Catheter-related infection Kingdom; Institute of Cardiovascular Sciences, The University of Manchester, Manchester, 3 - CSF infections United Kingdom; and Leiden University Medical Center, Leiden, The Netherlands - EVD To whom correspondence should be addressed: Catherine Pringle, M.Sc. - Silver EVDs [E-mail: [email protected]] Citation: World Neurosurg. (2016) 89:505-509. Abbreviations and Acronyms http://dx.doi.org/10.1016/j.wneu.2016.01.034 AI: Antibiotic-impregnated Journal homepage: www.WORLDNEUROSURGERY.org CSF: Cerebrospinal fluid EVD: External ventricular drain Available online: www.sciencedirect.com 1878-8750/$ - see front matter Crown Copyright ª 2016 Published by Elsevier Inc. All rights reserved.

WORLD NEUROSURGERY 89: 505-509, MAY 2016 www.WORLDNEUROSURGERY.org 505 ORIGINAL ARTICLE ROSS ATKINSON ET AL. CSF INFECTION WITH SILVER EVD use of preoperative antibiotics, antibiotic-impregnated (AI) with local anesthetic. The site of incision for the burr hole and the catheters, or silver-impregnated catheters.3,4,10,11 exit site of the EVD were marked before the operation. Silver- As a result of the reduced infection rates associated with AI or impregnated EVD catheters (Silverline; Spiegelberg GmbH & Co. silver-impregnated EVD catheters, more centers now use impreg- KG, Hamburg, Germany) were used in all patients. The EVD was nated catheters routinely. Moreover, an increasing number of subcutaneously tunneled at least 6 cm away from the main incision centers insert and attend to patients with EVDs using strict protocols site. Closure of the new wound was performed with interrupted and “bundles of care,” which have also been shown to reduce polyglactin 910 (VICRYL; Ethicon, Somerville, New Jersey, USA) infection rates independently.2,12 However, as most of the risk sutures to the galea aponeurotica and clips (if closing an old wound, factors for infections are reported in series of patients treated with clips were not used). The EVD was secured by under-running it, and “plain” EVD catheters or when strict protocols were not routinely the loops were fixed to the scalp with staples or silk sutures. An used; we do not know the risk factors for infection associated with AI Opsite IV3000 (Smith & Nephew, London, United Kingdom) dres- or silver EVD catheters in this setting. We have instituted an sing was applied to the wound and EVD exit site after careful drying. evidence-based bundle of care approach to reducing EVD-related The drainage system was attached in the operating room while the CSF infections and, similar to many centers in the world, use patient was still draped. The EVD was kept clamped while the pa- silver-impregnated EVD catheters as part of this bundle. The aim of tient was being transferred to his or her bed and was reopened soon this study was to determine which factors are associated with an after. The EVDs were not routinely changed or sampled. increased risk of CSF infection in patients with a silver EVD to ascertain where further improvements can be made. Definitions and Microbiology For the purpose of this study, CSF infection was defined as MATERIALS AND METHODS 1) positive microbiologic culture from the CSF alone or 2) where there was a strong suspicion of EVD-related infection from clinical Study Design signs and symptoms (fever, tachycardia, neurologic deterioration), This is a retrospective analysis of prospectively collected data on pa- a positive microbiologic blood culture was required as well as tients who underwent placement of an EVD at Salford Royal NHS diagnosis by a microbiologist. Care was taken to ensure suspected Foundation Trust, a large university teaching hospital and tertiary contaminants were excluded. Suspected infections without referral center for neurosurgery. The study was approved by the microbiologic confirmation were not included in this analysis. Proportionate Review Sub-committee of the National Research Ethics Service LondoneFulham Committee (reference 13/LO/1672). Statistical Analysis Statistical analysis was undertaken using SPSS for Windows (SPSS, Study Population Inc., Chicago, Illinois, USA). Univariate analysis was performed All adult patients (>18 years old) undergoing EVD placement at on all variables in relation to CSF infection: categorical variables the Greater Manchester Neurosciences Centre at Salford Royal using the c2 test; continuous, normally distributed variables using NHS Foundation Trust between October 1, 2011, and September analysis of variance; and continuous, nonenormally distributed 30, 2013, were eligible for inclusion. Patients with existing or variables using the Mann-Whitney U test. Binary logistic regres- previous infection of the CSF were excluded. sion was used to determine independent risk factors for CSF infection with infection as the dependent variable and CSF leak, Data Collection total duration of drainage, need for >1 EVD (replacement of an Data for all patients in whom an EVD was inserted within this time existing EVD), and bilateral EVDs as independent variables. Out- frame in the Department of Neurosurgery were accessed. During comes (mortality, discharge home, length of stay) were compared the study period, a dedicated EVD infection control program was using c2 tests and t test (Mann-Whitney) between patients with initiated, collating data regarding causative pathologies and and without infection to illustrate the impact of CSF infection. indications for EVD insertion, duration of external ventricular drainage, number of replacement EVDs, and infection rates and causative organisms identified. Patients were identified from the RESULTS Neurosurgery EVD database; a prospective log of all patients During the 24-month study period, 263 individual patients (286 undergoing EVD placement was designed to monitor EVD-related episodes of inpatient hospitalization) underwent placement of 362 CSF infection. silver-impregnated EVDs at our neurosurgery department. The median age of patients was 52 years, and most EVDs were placed Surgical Procedure in patients with subarachnoid hemorrhage. The baseline charac- All EVDs were inserted under sterile conditions in the neurosur- teristics are presented in Table 1. Most patients required unilateral gical operating room on an operating table, according to the local EVD placement (97%), but in 52 (18%) patients, replacement of Protocol for the Insertion and Management of EVDs for Neuro- the EVD was needed. Data regarding the EVD procedures science patients. Briefly, antibiotic prophylaxis (intravenous undertaken are presented in Table 2. The overall infection rate cefuroxime) was administered at the time of induction. The hair per patient episode was 5.2% (15 patients), and the infection was clipped at the burr hole incision site as well as the EVD exit rate per 1000 EVD drainage days was 6.42%. Patients with an site, followed by preoperative disinfection of the skin with 2% EVD infection had a significantly longer length of stay (P < chlorhexidine in 70% isopropyl alcohol solution (ChloraPrep; 0.001). The proportion of patients needing >1 EVD or who had CareFusion UK, Basingstoke, United Kingdom) and infiltration EVD-related CSF leak was higher in the infected group

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