How to reduce the risk of Ventriculoperitoneal (VP) shunt infection?

Reducing VP Shunt Infection Risk

Administer preoperative intravenous antibiotics and use antibiotic-impregnated shunt tubing to significantly reduce VP shunt infection rates. 1

Preoperative Antibiotic Prophylaxis

Use systemic intravenous antibiotics before shunt surgery to reduce infection risk from 10.7% to 5.9% (relative risk reduction of 45%). 1

• Administer antibiotics providing gram-positive coverage (first-generation cephalosporin, nafcillin, clindamycin, or vancomycin) before skin incision 1
• Continue prophylactic antibiotics for the first 24 hours postoperatively 2
• Meta-analysis of randomized controlled trials demonstrates a risk ratio of 0.55 (95% CI 0.38-0.81) favoring preoperative antibiotics 1
• This represents Level II evidence with moderate clinical certainty 1

Common Pitfall

Individual studies were underpowered to show benefit; only meta-analysis combining multiple trials demonstrated statistical significance. 1 Do not withhold antibiotics based on individual negative studies.

Antibiotic-Impregnated Shunt Hardware

Use antibiotic-impregnated shunt tubing for all pediatric shunt placements as it provides superior infection prevention compared to standard silicone hardware. 1

• Antibiotic-impregnated catheters reduce shunt infection with an odds ratio of 0.21 (95% CI 0.08-0.55) 2
• A multicenter randomized controlled trial demonstrated significant reduction in postoperative shunt infection, particularly in children 1
• This is now a Level I recommendation with high clinical certainty 1

Adjunctive Intraventricular Antibiotics

Consider intraventricular antibiotic administration at the time of surgery for high-risk patients, though this remains controversial. 3

• Combination of intraventricular gentamicin (4 mg) plus vancomycin (10 mg) with systemic antibiotics reduced infection rate to 0.4% compared to 5-7% with systemic antibiotics alone 3
• Postoperative injection of vancomycin and gentamicin in the reservoir and around the peritoneal catheter significantly reduced infection in infants under one year 4
• Intraventricular antibiotics extend prophylactic coverage into CSF and prevent bacterial seeding 3

Important Caveat

Potential neurotoxicity of intrathecal antibiotics may limit routine use; reserve for high-risk scenarios such as premature infants, age less than one month, or prolonged surgical duration (≥90 minutes). 1, 4

High-Risk Patient Identification

Target enhanced prophylaxis for patients with these risk factors:

• Prematurity (p=0.00236) 4
• Age less than one month (p<0.0001) 4
• Surgical duration ≥90 minutes (p<0.00001) 4
• Previous shunt infection 1
• Recent shunt revision 1

Most infections occur within the first 2 months after surgery, with 30 days being the mean time to infection. 1, 4

Surgical Technique Considerations

• Use neuronavigation technology for accurate ventricular catheter placement to minimize malposition 5
• Minimize operative time when possible, as duration ≥90 minutes significantly increases infection risk 4
• Ensure meticulous sterile technique, as most infections are caused by skin flora (coagulase-negative Staphylococcus, S. epidermidis, S. aureus) 1

Management of Infected Shunts

If infection occurs despite prophylaxis:

• Remove infected hardware completely when possible, as supplementation with partial or complete shunt removal is recommended for managing established infections 1
• Administer intravenous vancomycin for empiric coverage of methicillin-resistant staphylococci 6
• Consider adding rifampin if infection fails to respond to vancomycin or nafcillin monotherapy 6
• Place external ventricular drain until CSF is sterile before inserting new shunt 6