Tamber Mandeep S, Klimo Paul, Mazzola Catherine A, Flannery Ann Marie
Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
J Neurosurg Pediatr. 2014 Nov;14 Suppl 1:60-71. doi: 10.3171/2014.7.PEDS14328.
The objective of this systematic review was to answer the following question: What is the optimal treatment strategy for CSF shunt infection in pediatric patients with hydrocephalus?
The US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and based on the quality of the literature, recommendations were made (Levels I-III).
A review and critical appraisal of 27 studies that met the inclusion criteria allowed for a recommendation for supplementation of antibiotic treatment using partial (externalization) or complete shunt hardware removal, with a moderate degree of clinical certainty. However, a recommendation regarding whether complete shunt removal is favored over partial shunt removal (that is, externalization) could not be made owing to severe methodological deficiencies in the existing literature. There is insufficient evidence to recommend the use of intrathecal antibiotic therapy as an adjunct to systemic antibiotic therapy in the management of routine CSF shunt infections. This also holds true for other clinical scenarios such as when an infected CSF shunt cannot be completely removed, when a shunt must be removed and immediately replaced in the face of ongoing CSF infection, or when the setting is ventricular shunt infection caused by specific organisms (for example, gram-negative bacteria).
Supplementation of antibiotic treatment with partial (externalization) or complete shunt hardware removal are options in the management of CSF shunt infection. There is insufficient evidence to recommend either shunt externalization or complete shunt removal as the preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required. In addition, there is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection when the infected shunt hardware cannot be fully removed, when the shunt must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.
Supplementation of antibiotic treatment with partial (externalization) or with complete shunt hardware removal is an option in the management of CSF shunt infection.
Level II, moderate degree of clinical certainty.
There is insufficient evidence to recommend either shunt externalization or complete shunt removal as a preferred surgical strategy for the management of CSF shunt infection. Therefore, clinical judgment is required.
Level III, unclear degree of clinical certainty.
There is insufficient evidence to recommend the combination of intrathecal and systemic antibiotics for patients with CSF shunt infection in whom the infected shunt hardware cannot be fully removed or must be removed and immediately replaced, or when the CSF shunt infection is caused by specific organisms. The potential neurotoxicity of intrathecal antibiotic therapy may limit its routine use.
Level III, unclear degree of clinical certainty.
本系统评价的目的是回答以下问题：小儿脑积水患者脑脊液分流感染的最佳治疗策略是什么？
使用与本系统评价目的相关的医学主题词和关键词检索美国国立医学图书馆及Cochrane系统评价数据库。对摘要进行审查，之后选择符合纳入标准的研究，并根据证据质量（I-III级）进行分级。构建证据表以总结相关研究结果，并根据文献质量给出推荐意见（I-III级）。
对27项符合纳入标准的研究进行回顾和严格评价后，以中等程度的临床确定性推荐使用部分（外置）或完全移除分流硬件来辅助抗生素治疗。然而，由于现有文献存在严重的方法学缺陷，无法就完全移除分流器是否优于部分移除分流器（即外置）给出推荐意见。没有足够的证据推荐在常规脑脊液分流感染的管理中使用鞘内抗生素治疗作为全身抗生素治疗的辅助手段。对于其他临床情况也是如此，例如当感染的脑脊液分流器无法完全移除时、当面对持续的脑脊液感染必须移除分流器并立即更换时，或者当感染是由特定病原体（如革兰氏阴性菌）引起的脑室分流感染时。
在脑脊液分流感染的管理中，可选择用部分（外置）或完全移除分流硬件来辅助抗生素治疗。没有足够的证据推荐将分流器外置或完全移除作为脑脊液分流感染管理的首选手术策略。因此，需要临床判断。此外，当感染的分流硬件无法完全移除、必须移除分流器并立即更换，或者脑脊液分流感染由特定病原体引起时，没有足够的证据推荐对脑脊液分流感染患者联合使用鞘内和全身抗生素。鞘内抗生素治疗的潜在神经毒性可能会限制其常规使用。
在脑脊液分流感染的管理中，可选择用部分（外置）或完全移除分流硬件来辅助抗生素治疗。
II级，中等程度的临床确定性。
没有足够的证据推荐将分流器外置或完全移除作为脑脊液分流感染管理的首选手术策略。因此，需要临床判断。
III级，临床确定性不明确。
当感染的分流硬件无法完全移除或必须移除并立即更换，或者脑脊液分流感染由特定病原体引起时，没有足够的证据推荐对脑脊液分流感染患者联合使用鞘内和全身抗生素。鞘内抗生素治疗的潜在神经毒性可能会限制其常规使用。
III级，临床确定性不明确。
