Hydrocephalus is a disease condition in which excessive Cerebral Spinal Fluid (CSF) will be accumulating within the cerebral ventricular system, leading to raised Intracranial Pressure (ICP). This condition apparently can result from various conditions that can affect a fetus, infant, child and adult. Numerous 50 descriptions of hydrocephalus were proposed, the summary of which indicates an underlying disparity of the production of CSF from its absorption [1]. 

The choroid plexus responsible for production majority of CSF, contributing for the daily volume of 70–80%. A small fraction of CSF may be produced from the ependymal and brain parenchyma. CSF production occurs by an amalgamation of filtration crosswise the endothelium and sodium-active secretion of by the choroidal epithelia. Although the cerebral perfusion pressure and ICP do appear to have some effect on CSF production, it is largely independent of these pressures under physiological conditions. CSF which is largely produced in the lateral ventricles bypassed from the foramen of Monroe into the third cerebral ventricle and reaches the fourth ventricle through the Sylvius aqueduct and then apparently exits throughout median foramen of Magendi and the lateral foramina of Luschka [2,3].

Nearly 40% of freshly implanted shunts failed within the first year, with an infection rate of 8.1 percent throughout a follow-up period of one-to-three year. These figures show the rate of shunt infection after a single shunt surgery. Patients who are observed for longer periods of time have a higher chance of developing shunt infection as a result of several shunt procedures, ranging from 19% to 38%. Despite the fact that there was a self-reporting bias, the Hydrocephalus-Association database revealed that over 40% of individuals with hydrocephalus for at least 10 years had as a minimum one shunt infection [3-5]. Although preventive measures may reduce shunt infection rates, a reasonable conclusion is that the overall infection rate for new shunts is between 3 and 8%. In comparison to past statistics, it appears that shunt infection rates have been steadily decreasing [2].

Although greater attention to sterile technique, preoperative antibiotics and enhanced surgical technique may all play a role, it is unclear what variables have contributed to this drop [2,3].

Fever, headache and pain in the setting of a recent shunt procedure are the usual symptoms reported to occur with infection. The actual presentation can vary and is dependent on the virulence of the organism and the location of the infection. It is useful to consider shunt infections as being present in three locations: within the ventricles and shunt, in the abdomen, or around the shunt hardware in the subcutaneous tissues. A shunt infection caused by low-virulence organism’s results in pleocytosis and eventual shunt blockage, with symptoms such as headache and vomiting. Even when fever absent, shunt infection is still a possibility [6-9].

Imaging investigations aid in the detection of shunt infection in a roundabout way. Plain radiographs are generally used to check whether a shunt system is in good working order. Rarely, plain radiographs demonstrate a specific finding, such as air within the peritoneal cavity, that is strongly suggestive of a shunt infection. In many cases shunt infection causes some degree of shunt obstruction and results in findings consistent with that diagnosis, such as increased ventricular size [10]. Complex shunt infections, associated with multicompartmental hydrocephalus, severe ventriculitis, or resistant or virulent organisms, result in dramatic findings [11].

Skin swabs are rarely helpful in isolating the exact organism because cross-contamination invariably occurs. In most other situations, confirmation of a shunt infection and identification of the causative organism require a CSF sample. This is most commonly obtained by percutaneous aspiration of the shunt through the cranial reservoir. Even if there is some degree of proximal shunt obstruction, CSF can usually be obtained. If the proximal portion of the shunt is completely obstructed and symptoms are suggestive of shunt infection, there are two options. A small-volume lumbar puncture (2 mL) can be performed if there is no sign of elevated intracranial pressure. It is important to note that the possibility of a shunt infection not excluded by a negative lumbar puncture result. Shunt investigation is indicated if the patient shows symptoms of high intracranial pressure [4,5,8]. Polymerase Chain Reaction (PCR) has verified a powerful device in the recognition of a wide range of clinically imperative infectious diseases including CSF shunt ventriculostomy infection [10].

Most shunt infections caused by staphylococcal species do not cause significant tissue damage or a severe inflammatory response. Intravenous antibiotic treatment usually results in rapid bacteriogic clearance, with resolution of the CSF pleocytosis. Persistence of viable bacteria in or around the shunt hardware usually precludes the use of antibiotics as the sole treatment for shunt infections. The preponderance of shunt infections require shunt removal surgically [12], inserting of an external CSF drain and several days of intravenous antibiotics. The shunt is usually not placed until CSF cultures are negative for bacterial growth. The recommended interval between shunt removal and reinsertion averages approximately 10 to 14 days, with at least 48 hours between the final negative CSF culture and reinsertion [13].

In post-neurosurgery patients with ventriculitis and meningitis, giving antibiotics (whether intra-ventricular or lumbar intra-thecal) can result in very rapid CSF sterilization. All patients treated have a very low recurrence rate of ventriculitis and/or meningitis [14]. Antibiotics administered intra-ventricularly/lumbarly intra-thecally appear to be an efficient and adequate treatment for CNS infections of multidrug-resistant bacteria [15].

External Ventricular Drainage (EVD) is a life-saving technique for decreasing intracranial hypertension caused by a blockage in the flow of Cerebrospinal Fluid (CSF). It's a straightforward but life-saving procedure. This procedure provides a temporary environment in which CSF that is unable to pass through ordinarily can be extracted [1]. 

Clinical determinants for EVD implantation, according to Ranger et al. comprise traumatic injury (36%), hydrocephalus (35%) and ventriculo-peritoneal shunt failure (29%). About 65% of EVDs were placed at the bedside in the Pediatric Critical Care Unit (PCCU), whereas 33% were placed in the operating room (OR). The average time it took to implant an EVD was 7.0 days. Infection (9.4%), misplacement (6.3%), bleeding (4.2%), blockage (3.1%) and malfunction were among the 26% of EVD placements that resulted in complications (3.1%). Coagulase-negative Staphylococcus aureus was the predominant infecting agent (67% of infections). EVD consequences were similar in traumatic injury patients and hydrocephalus patients, despite TBI patients having considerably lesser lateral ventricles (Risk ratios 1.41). Furthermore, whether EVDs were put in the PCCU or OR, similar complication rate was reported [16]. 

Antibiotics or catheters impregnated with antimicrobials that target coagulase-negative Staphylococcus may help to prevent EVD infections. A shunt is placed in the right frontal horn of the lateral ventricle during the surgery. It's frequently done without any kind of picture assistance, which can be dangerous. The surgical procedure is determined by the patient's clinical condition, clinical exam and imaging [Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI)]. Surface anatomy is used to accomplish EVD, which is considered a simple process. It is usually the first surgery that a young resident or neurosurgeon performs [2].

Although the lateral ventricle is usually enlarged, the neurosurgeon occasionally encounters cases where the frontal horn is normal or even narrow. As a result, understanding the cranial projections of brain areas is critical for surgical success and avoids surgical problems and catheter misplacement. It was believed that implementing EVD inside the third ventricle is the most excellent technique to achieve a circumstance closer to reality as possible, based on experience and the logic and diseases conditions needed EVD on the one hand and representing brain anatomy and the physiopathology of CSF circulation and absorption on the other.

The insertion of a needle to reach the lateral ventricle is known as a Ventricular tap. In babies, a no. 22 needle accompanied by a stylet is placed in the anterior fontanel through the scalp. The test carried out also to determine how much pressure is found in the spinal fluid. A range of settings, including radiology departments, dedicated procedure areas and patient care units, are used to perform neurological diagnostic procedures. Ventricular tapping is used to detect infections in the ventricle [17].

A ventricular tap is used to:

• Drain cerebrospinal fluid in non-communicating hydrocephalus

• Recognize the symptoms of ventriculitis

• Inject medicines into the ventricles

A ventricular tap is a sterile aseptic procedure conducted by medical personnel who have been trained in the operation. An ultrasound should be conducted prior to a ventricular tap to check ventriculomegaly and measures made to validate the depth and direction of needle insertion [17,18].

 Aim of Study     

To compare the efficacy and outcome of EVD versus ventricular tap in the management of infected hydrocephalus in infancy.

Patients and Methods: This is a clinical prospective study on (40) patients with infected hydrocephalus were presented to AL-Shahid Ghazi Al-Shaheed Ghazi Al-Hariri hospital (medical city) from July 2015 to February 2017. All patients had computed tomography study of the brain to confirm hydrocephalus. Ventricular tap performed to draw CSF sample which was sent for CSF analysis to confirm CSF infection.

All patients with infected hydrocephalus were given triple antibiotic (Amoxicillin, Ceftriaxone and metronidazole) therapy than changed according to culture and sensitivity or the causing microorganism. Antibiotic was given either intravenous, intraventricular or both with combination of two drugs at least. The study carried out in two groups (37 patients in EVD group and 18 patients in the ventricular tap group) both of them under cover of different regimen of antibiotics all through the course of this inquiry.

The first group (37 patients) was selected to have external drain as a part of their management with follow up by CSF analysis to determine infection clearance and response to treatment. Those who had clear CSF were either needed V-P shunt to treat their hydrocephalus or ended as arrested hydrocephalus. Others failed to respond to EVD as a mode of therapy and were addressed for ventricular tapping or discharged on their parent’s responsibility. The Ventricular Tapping (VT) group (18 patients) were collected from either a newly diagnose infected hydrocephalus or those who failed EVD therapy.

Ventricular tapping was done every three days to determine the response to treatment by assessing the new CSF analysis parameters and signs of increase ICP. In this group patients were followed up either at home (with instructions for signs and symptoms of raised ICP) or admitted to hospital for those with associated medical illnesses or those unable to pay for treatment.

Data were collected regarding the number of admission, duration of admission, number of ventricular tapping or EVD used, duration on treatment, results of culture and sensitivity, antibiotic used and duration and the result of treatment.

Table 1 demonstrates the cause of hydrocephalus and reveals that the most common cause of hydrocephalus is congenital hydrocephalus representing 62.5% while IVH is the least accounts for only 5.0% of the sample.

Table 1 cause of hydrocephalus and their percentages.

Table 2 demonstrates the causes for infected hydrocephalus and shows that the infection, most commonly caused by meningitis, while infected meningeomyelocele is the least in the group study.

Table 3 shows number of admission in EVD group and depicts that, most of the patients have more than one admission during the study period. Some of them reached ten admissions.

Table 4 shows duration of admission in days in EVD group and reveals that the long hospital stay associated with many patient in EVD group, some of them reached up to 200 days. 70% of the study group has hospital stay between 1-50 days.

Table 5 shoes that Amoxicillin and Ceftriaxone was the main antibiotic used in EVD group (27%). While meropenem was used in two patients only.

Table 6 demonstrates the number and percentage of patients with culture and sensitivity in EVD group and shows that the majority of patients had no culture and sensitivity.

Table 1: Cause of Hydrocephalus and their Percentages

Table 2: Cause of Infected Hydrocephalus in EVD Group

Table 3: Number of Admission in EVD Group

Table 4: Duration of Admission in days in EVD Group

Table 5: Antibiotics used in EVD Group and their Percentage

Table 6: Number and Percentage of Patients with Culture and Sensitivity in EVD Group

Table 7: Microorganisms Involved According to Culture and Sensitivity in EVD Group

Table 8: Result of Treatment in EVD Group

Table 9: Number of Ventricular Tap per Patient in Ventricular Tap Group

Table 10: Duration of Ventricular tap (days/patient) in Ventricular Tap Group

Table 11: Number of Admission per Patient in Ventricular Tap Group

Table 12: Duration of Admission (Days/Patient) in Ventricular Tap Group

Table 13: Antibiotics used in Ventricular tap Group and Their Percentage

Table 14: Micro Organisms Involved according to Culture and Sensitivity in Ventricular Tap Group

Table 15: Result of Treatment in Ventricular Tap Group

Table 7 demonstrates the microorganisms involved according to culture and sensitivity in EVD group and depicts that the most common microorganism encountered according to culture and sensitivity in the EVD group was Pseudomonas aeruginosa (25%).

Table 8 demonstrates the result of treatment in EVD group and reveals that the most of the patient in the EVD group (60%) had no benefit and CSF was still infected. Two deaths was reported in the study group.

Table 9 demonstrates the number of ventricular tap per patient in ventricular tap group and shows that the most of the patients (44%) had 1-3 ventricular tap in the group study, while few (12%) had more than six ventricular tap.

Table 10 shows the duration of ventricular tap (days/patient) in ventricular tap group and records that short hospital stay was noted in the majority of ventricular tap group (50%) and the longest hospital stay was one most in only 11%.

Table 11 demonstrates the number of admission per patient in ventricular tap group and shows that 89% of the ventricular tap group had only one admission.

Table 12 shows the duration of admission (days/patient) in ventricular tap group and demonstrates that short hospital stay was evident the majority of ventricular tap group (55%). While only one patient had hospital stay of more than 21 days.

Table 13 shows the antibiotics used in ventricular tap group and their percentage and reveals that the Vancomycin was the most single antibiotic used in the ventricular tap group (28%), while the highest percentage of patients (35%) had different combination of more than one drug.

Table 14 shows the microorganisms involved according to culture and sensitivity in ventricular tap group and demonstrates that the Klebseilla was the most common microorganism encountered (28%) according to culture and sensitivity in the ventricular tap group. Staphylococcus aureus was evident in only three patients.

Table 15 demonstrates the result of treatment in ventricular tap group and shows that the majority of patients had good result in the ventricular tap group and clear CSF in 89%. No death was reported.

Forty patients with infected hydrocephalus were presented from July 2015 to February 2017 to Al-Shahid Ghazi Al-Hariri hospital (medical city). The following will be discussed.

The study group included those less than one year old, as the fontanel is usually not closed at this age and access to the ventricles by ventricular tapping through fontanel can be done. The age’s mean of presentation was 90 days old. In one cohort study, children 6 months or younger had a 19% rate of infection, versus 7% among older children [19]; this finding is similar to the reports of other groups. According to Kee et al. [12] the age’s mean of presentation was one month. The study group included 26 males (65%) and 14 females (35%) patients. The male/female ration was 1.85:1. According to Sergio F. Salvador et al. the male/female ratio was 1:1 [20]. 

Cause of hydrocephalus was assessed by history, clinical examination and CT brain. About 25 patients (62.5%) were diagnosed as congenital hydrocephalus (congenital aqueductal stenosis). Post-menigitis as a cause of hydrocephalus was noticed in 13 patients (32.5%). Intra-ventricular hemorrhage presented to be the cause of hydrocephalus in two patients (5%).

For the EVD study group, 37 patients were selected as a mode of therapy. The cause of infection in this group was determined by history, clinical examination and CSF analysis. 14 patients (37%) were due to meningitis. 13 patients (35%) were due to infected V-P shunt. 4 patients (10%) were due to infected myelomeningeocele. According to Ashraf et al. frequent cause of infected hydrocephalus is meningitis 45% and infected V-P shunt in 30% [21]. 

In the EVD group, 71 devices were used with the mean of 1.9 devices per patient. The mean duration on EVD therapy per patient was 36.9 days/patient. The rate of admission was 2.4 admission/patient in the EVD group. The mean duration of admission was 50.3 days per patient. CSF culture and sensitivity was conducted in 15 patients (40%) only. Some of the patients received treatment based on the common offending microorganisms without doing culture and sensitivity. The microorganisms involved according to culture and sensitivity in the EVD group were as follow:

Pseudomonas aeruginosa in 4 patients (25%). Klebseilla in 4 patients (25%). Staphylococcus aureus in 2 patients (12.5%). Actinobacterbaumanniin 2 patients (12.5%). Staphylococcus epidermidis in 2 patients (12.5%). E.coli in one patient (6.25%). Ochrobactrumanthropi in one patient (6.25%).

According to Kee et al. [12] the most widespread causative microorganism was coagulase-negative staphylococci in 45.7% followed by Staphylococcus Aureus in 22.9%. Methicillin resistance rate was 83.3% among Coagulase-negative staphylococci and S. Aureus.

The duration’s mean of treatment undercover of antibiotics was 25.8 days/patient. Clear CSF was attained in 13 patients (35%). The death rate in EVD group patients was 5% (two patients). Kestle et al. reported that re-infection rate in their study was 26%. Approximately 2/3 of the re-infections were the result of the same organism, suggesting a failure to completely eradicate the original infection. Surprisingly, the re-infection rate was not affected by the interval of antibiotic therapy. This suggests that other factors such as resistance or lack of antibiotic penetration may account for re-infection.

Among the ventricular tap group, 18 patients were selected for the ventricular tapping mode of therapy and the ventricular tapping was done every three days or when needed if the patient developed bulging fontanel or sign and symptoms of elevated intracranial pressure. Parents of those patients who followed up at home were instructed about how to assess for bulging fontanel and informed to call if their patient develops signs and symptoms of raised intracranial pressure in order to do ventricular tap at hospital. The rate of ventricular tap per patient was 4 ventricular tap/patient. The mean duration on ventricular tapping per patient was 12.7 days/patient. The rate of admission was 1.1 admission/patient. The mean duration of admission per patient was 12.2 days/patient.

All patients of the ventricular tapping group had CSF for culture and sensitivity. The antibiotic choice was according to the offending microorganism and its sensitivity.

The following microorganisms were found to be the cause of infection in the ventricular tap group: Klebseilla in 5 patients (28%). Pseudomonas aeruginosa in 4 patients (22%). Staphylococcus aureus in 3 patients (16%). Staphylococcus epidermidis in 3 patients (16%). Actinobacterbaumannii in 2 patients (11%). E. coli in one patient (7%). The mean duration on the antibiotic used was 13.1 days/patient.

Present study found that 16 patients (89%) had clear CSF analysis and two patients (11%) did not find cure in this group of study. According to frassanito et al. [22], SecurAcath is a harmless and helpful device to secure CSF external catheters to the skin, with numerous applicable advantages: its installation and maintenance are effortless; it may resides in place for the full duration of the catheter; it permits a more whole antisepsis of the exit location, thus dropping local skin complications; it reduces the risk of suture-related needles tick injuries. 

The infection rate is the same whether the EVD is long-tunneled or short-tunneled. Long-tunneled EVDs, according to Tahir et al. appear to just delay possible infections while having no influence on the actual risk of infection [23].

Post infective hydrocephalus is the main familiar kind of hydrocephalus in underdeveloped countries. Infected CSF cannot be shunted because of its high protein level, which will obstruct the chamber of the ventriculo-peritoneal shunt. A makeshift feeding tube can be utilized in facilities where normal EVD units are not accessible [24].

In children with VPS infection, the EVD device should be updated every 10 days to ensure that the infection is resolved quickly [23]. 

EVDs are linked to high infection rates and EVD infections result in important morbidity and mortality. The achievement of an evidence-based EVD infection control program has the potential to minimize the number of EVD infections.

• Infected hydrocephalus patients are somewhat more likely to be male

• Most patients with infected hydrocephalus were below 4 months

• The most widespread cause of infected hydrocephalus was meningitis (37%)

• Patients with EVD had multiple admissions, longer hospital stay and longer duration on antibiotic treatment with lower cure rate (35%)

• Those with ventricular tapping had less rate of admission (some of them even followed up at home) and shorter hospital stay

• The duration on antibiotics in the ventricular group was shorter with a higher rate of cure (89%)

• In the EVD group, the mortality rate was higher

Recommendation

• EVD should be installed and cared according the EVD care protocol

• EVD should be changed every 10 days

• In the ventricular tapping group; the number of ventricular tap should be as less as possible to prevent further brain tissue damage

• Improve hospital hygiene to decrease the risk of nosocomial infection

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