VP Shunt Infection

1
VP Shunt Infection

• Supichaya Netsawang,MD.
• Division of Infectious Diseases Department of
  PediatricsQueen Sirikit National Institute of
  Child Health

2
Childs Nerv Syst 199814378-80.
3
CSF is produced in the ventricles by the choroid
plexus at a rate of approximately 20 ml/h in
adults (8 ml/h in infants).
Childs Nerv Syst 199814378-80.
4

• Normal conditions, a perfect equilibrium exists
  between secretion and absorption of CSF.

Childs Nerv Syst 199814378-80.
5

• Hydrocephalus is a pathological condition which
  occurs as a result of imbalance between the
  production and absorption of CSF.  

Childs Nerv Syst 199814378-80.
6
Normal Hydrocephalus
Pathi R et al. Australas Radiol 20044861-3.
7

• A CSF shunt involves establishing an accessory
  pathway for the movement
• of CSF in order to bypass an obstruction of
  the natural pathways.
• CSF shunt system
• 1.Proximal catheter
• 2.Reservoir
• unidirectional valve
• (anti-reflux valve) 
• 3.Distal catheter

Childs Nerv Syst 199814378-80.
8
Proximal catheters
Childs Nerv Syst 199814378-80.
9
Reservoir
Childs Nerv Syst 199814378-80.
10
Reservoir
Childs Nerv Syst 199814378-80.
11
Distal catheter
Childs Nerv Syst 199814378-80.
12
Ventriculoperitoneal shunt(VP shunt) Ventriculoatr
ial shunt(VA shunt) Lumboperitoneal shunt(LP
shunt)
Childs Nerv Syst 199814378-80.
13
Complication of CSF shunt

• Obstruction most common
• Infection
• Overdrainage subdural hematoma
• slit ventricle
  syndrome
• Orthers disconnection
• silicone allergy

Childs Nerv Syst 199814378-80.
14
Obstruction
Childs Nerv Syst 199814378-80.
15
Overdrainage
Pathi R et al. Australas Radiol 20044861-3.
16
Incidence

• Early report infection rate 5-27
• Current report infection rate 2.1-11

Childs Nerv Syst 199814378-80.
17
Common pathogen Staphylococus species 50-75
- S. epidermidis - S. aureus
Clin Microbiol Infect 20006
18
Candida
E. coli
Clin Microbiol Infect 20006
19
Proprionibacterium acnes

• Gram positive rod, anaerobe
• Children
• Low virulence (similar to S. epidermidis)
• Skin pilosebaceous gland
• scalp most heavily colonized
• Incidence 14.6
• Shunt obstruction
• CSF profile nearly normal

Childs Nerv Syst 199814378-80.
20
Pathogenesis

• Shunt implanted foreign body
• Fibronectin,fibrinogen and collagen
• ??????? shunt
• Staphylococci ???????? glycolipid (slime)

Childs Nerv Syst 199814378-80.
21
Diagnosis
Childs Nerv Syst 199814378-80.
22

• Age
• Wang et al. children group(lt16 y) 9.3
• adult group(gt16y) 1.7
• 
  Jpn J Infect Dis
  200457
• Kulkarni et al. preterm GAlt40 wk
• GAgt40 wk no increase infection rate
• J
  Neurosurg 200194
• Bruinsma et al. preterm GAlt37 wk and/or low
  birth weightlt 2000g high risk for infection
• Clin
  Microbiol Infect 20006

23

• Cause of hydrocephalus
• myelomeningocele
• infection rate 15

Childs Nerv Syst 199814378-80.
24

• Post operative CSF leakage
• infection rate 85.7
• Glove holes and shunt handling
• 
  Kulkarni AV et al. J Neurosurg 200194195-201.
• Limited surgeon experience with CSF shunt

Childs Nerv Syst 199814378-80.
25
Symptoms and Signs

• External shunt infection
• cellulitis, infected surgical wound
• Internal shunt infection
• meningitis, ventriculitis
• infected pseudocyst

Childs Nerv Syst 199814378-80.
26
Erode skin
27
Abscess
28

• Fever
• Headache
• Vomiting
• Stiff neck
• Papilledema
• Pediatric group
• Irritability
• Bulging fontanel

Clin Microbiol Infect 20006
29
Pseudocyst

• Complication of VP shunt
• Literature 95 case
• symptom abdominal pain 63
• signs abdominal distension 37
• tenderness 31
• mass 29
• Related history CNS infection 41.6

Childs Nerv Syst 199814378-80.
30
Pathi R et al. Australas Radiol 20044861-3.
31
Pseudocyst

• suggested that smaller pseudocysts tend to be
  infected, and larger pseudocysts tend to be
  sterile.
• 
  

Pathi R et al. Australas Radiol 20044861-3.
32
Treatment

• Surgical treatment
• -remove implanted foreign bodies
• -pus drainage
• Medical treatment
• -antibiotics
• -antifungal agents

Pathi R et al. Australas Radiol 20044861-3.
33

• Surgical treatment
• 1.Complete removal of the shunt without immediate
  replacement
• 2.Complete removal of the shunt with placement of
  EVD
• 3.Externalization of the shunt
• 4.Complete removal of the shunt with immediate
  replacement

Pathi R et al. Australas Radiol 20044861-3.
34
External Ventricular Drainage
35
Medical treatment

• ????????????????????????
• multi-drug resistant ,mixed infection
• Wang et al.
• -15/46 (30) ???? oxacillin-resistant
  staphylococus strain
• - 7/36 (19) ???? mixed infection
• recommend initial empirical antibiotic
• Vancomycinthird gen cephalosporin.

Jpn J Infect Dis 20045744-8.
36
Protocol for treatment of shunt infection
Jpn J Infect Dis 20045744-8.
37
Prevention

• Preoperative antibiotic
• Strict adherence to sterile technique
  asepsis, antisepsis, antimicrobial therapy and
  avoidance of hematoma
• Choksey and Malik
• 176 operations ?? infected shunt 1 ???
• ( acute
  appendicitis)
• culture Streptococcus fecalis

J Neurol Neurosurg Psychiatry 20047587-91.
38
Survival and prognosis

• 70 of shunt infection ???????? 2
  ?????????????????? shunt ??? 80 ????????? 6
  ?????
• 
  J Neurosurg 1984601014-21
• Gottfried et al. 60 ????????? shunt
  ??????????????????????1 ?? ???????????????????????
  50 ??? 2 ??
• - early shunt failure ???????????????? 2
  ???????????????????
• proximal failure
• - distal failure ?????????????????? 2
  ???????? ????????????????????????????????????????
  74 ???????????????????????????????????????????

Acta Neurochir (Wien) online 2004 Dec 21
39
Survival and prognosis

• Anaerobe infection poor prognosis
• mortality rate ???????? 50 .

Pediatr Neurol 20022699-105
40
Conclusion

• Shunt malfunction most common presenting
  syndrome for shunt infection
• ???????????????? shunt ???????????????????????????
  ???????????????????????
• CSF ??? shunt
• Most shunt infection occur within 2 months of
  operation
• ??????????????????????????????????? shunt ?????
• -strict adherence to sterile technique
  asepsis, antisepsis, antimicrobial therapy and
  avoidance of hematoma

Pediatr Neurol 20022699-105
41
??????????????????????? ???????????? ?.?.
????-????

• ??????? Infected VP-shunt

Collective Review Shunt Infection In
Chulalongkorn hospital
42
???????????????????????????
Collective Review Shunt Infection In
Chulalongkorn hospital
43
??????????????????????????? ????????????????
Collective Review Shunt Infection In
Chulalongkorn hospital
44
??????????????????????????????????????
Collective Review Shunt Infection In
Chulalongkorn hospital
45
????????????????????????????
Collective Review Shunt Infection In
Chulalongkorn hospital
46
????????????? CSF culture
Collective Review Shunt Infection In
Chulalongkorn hospital
47
??????????????????????????????????????????????????
?
Collective Review Shunt Infection In
Chulalongkorn hospital
48
CID 200336 (1 April) McGirt et al.
49
CID 200336 (1 April) McGirt et al.
50
CID 200336 (1 April) McGirt et al.
51
CID 200336 (1 April) McGirt et al.
52
J Microbiol Immunol Infect 20033647-50
53
J Microbiol Immunol Infect 20033647-50
54
J Microbiol Immunol Infect 20033647-50
55
J Microbiol Immunol Infect 20033647-50
56
Indian Journal of Medical Microbiology, (2006) 24
(1)52-4
57
Indian Journal of Medical Microbiology, (2006) 24
(1)52-4
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
THANK YOU