Simon Tamara D, Hall Matthew, Dean J Michael, Kestle John R W, Riva-Cambrin Jay
Division of Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
J Neurosurg Pediatr. 2010 Sep;6(3):277-85. doi: 10.3171/2010.5.PEDS09457.
Significant variation exists in the surgical and medical management of CSF shunt infection. The objectives of this study were to determine CSF shunt reinfection rates following initial CSF shunt infection in a large patient cohort and to determine management, patient, hospital, and surgeon factors associated with CSF shunt reinfection.
This retrospective cohort study included children who were in the Pediatric Health Information System (PHIS) database, who ranged in age from 0 to 18 years, and who underwent uncomplicated initial CSF shunt placement in addition to treatment for initial CSF shunt infection between January 1, 2001, and December 31, 2008. The outcome was CSF shunt reinfection within 6 months. The main predictor variable of interest was surgical approach to treatment of first infection, which was determined for 483 patients. Covariates included patient, hospital, surgeon, and other management factors.
The PHIS database includes 675 children with initial CSF shunt infection. Surgical approach to treatment of the initial CSF shunt infection was determined for 483 children (71.6%). The surgical approach was primarily shunt removal/new shunt placement (in 286 children [59.2%]), but a substantial number underwent externalization (59 children [12.2%]), of whom a subset went on to have the externalized shunt removed and a new shunt placed (17 children [3.5% overall]). Other approaches included nonsurgical management (64 children [13.3%]) and complete shunt removal without shunt replacement (74 children [15.3%]). The 6-month reinfection rate was 14.8% (100 of 675 patients). The median time from infection to reinfection was 21 days (interquartile range [IQR] 5-58 days). Children with reinfection had less time between shunt placement and initial infection (median 50 vs 79 days, p = 0.06). No differences between those with and without reinfection were seen in patient factors (patient age at either shunt placement or initial infection, sex, race/ethnicity, payer, indication for shunt, number of comorbidities, distal shunt location, and number of shunt revisions at first infection); hospital volume; surgeon volume; or other management factors (for example, duration of intravenous antibiotic use). Nonsurgical management was associated with reinfection, and complete shunt removal was negatively associated with reinfection. However, reinfection rates did not differ between the 2 most common surgical approaches: shunt removal/new shunt placement (44 [15.4%] of 286; 95% CI 11.4%-20.1%) and externalization (total 12 [20.3%] of 59; 95% CI 11.0%-32.8%). Externalization followed by shunt removal/new shunt placement (5 [29.4%] of 17; 95% CI 10.3%-56.0%) and nonsurgical management (15 [23.4%] of 64; 95% CI 13.8%-35.7%) had higher, but nonstatistically significant, reinfection rates. The length of stay was shorter for nonsurgical management.
Surgical approach to treatment of initial CSF shunt infection was not associated with reinfection in this large cohort of patients.
脑脊液分流感染的手术和药物治疗存在显著差异。本研究的目的是确定一大群患者初次脑脊液分流感染后的脑脊液分流再感染率，并确定与脑脊液分流再感染相关的治疗、患者、医院和外科医生因素。
这项回顾性队列研究纳入了儿科健康信息系统（PHIS）数据库中的儿童，年龄在0至18岁之间，他们在2001年1月1日至2008年12月31日期间除接受初次脑脊液分流感染治疗外，还接受了无并发症的初次脑脊液分流置管。结局指标是6个月内的脑脊液分流再感染。主要的预测变量是首次感染的手术治疗方法，对483例患者进行了评估。协变量包括患者、医院、外科医生和其他治疗因素。
PHIS数据库包括675例初次脑脊液分流感染的儿童。确定了483例儿童（71.6%）初次脑脊液分流感染的手术治疗方法。手术方法主要是分流器移除/新分流器置入（286例儿童[59.2%]），但有相当数量的儿童接受了外置引流（59例儿童[12.2%]），其中一部分随后进行了外置分流器移除和新分流器置入（17例儿童[总体3.5%]）。其他方法包括非手术治疗（64例儿童[13.3%]）和完全移除分流器而不更换分流器（74例儿童[15.3%]）。6个月再感染率为14.8%（675例患者中的100例）。从感染到再感染的中位时间为21天（四分位间距[IQR]5 - 58天）。再感染儿童在分流置管和初次感染之间的时间较短（中位时间50天对79天，p = 0.06）。在患者因素（分流置管或初次感染时的患者年龄、性别、种族/民族、付款人、分流指征、合并症数量、远端分流位置以及首次感染时分流器修订次数）、医院量、外科医生量或其他治疗因素（例如静脉使用抗生素的持续时间）方面，再感染组和未再感染组之间没有差异。非手术治疗与再感染相关，完全移除分流器与再感染呈负相关。然而，两种最常见的手术方法之间的再感染率没有差异：分流器移除/新分流器置入（286例中的44例[15.4%]；95%CI 11.4% - 20.1%）和外置引流（59例中的12例[20.3%]；95%CI 11.0% - 32.8%）。外置引流后进行分流器移除/新分流器置入（17例中的5例[29.4%]；95%CI 10.3% - 56.0%）和非手术治疗（64例中的15例[23.4%]；95%CI 13.8% - 35.7%）的再感染率较高，但无统计学意义。非手术治疗的住院时间较短。
在这个大型患者队列中，初次脑脊液分流感染的手术治疗方法与再感染无关。
