Arts Sebastian Hhmj, Boogaarts Hieronymus Damianus, van Lindert Erik J
Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, Netherlands.
Cochrane Database Syst Rev. 2019 Jun 4;6(6):CD012902. doi: 10.1002/14651858.CD012902.pub2.
The main complication of cerebrospinal fluid (CSF) shunt surgery is shunt infection. Prevention of these shunt infections consists of the perioperative use of antibiotics that can be administered in five different ways: orally; intravenously; intrathecally; topically; and via the implantation of antibiotic-impregnated shunt catheters.
To determine the effect of different routes of antibiotic prophylaxis (i.e. oral, intravenous, intrathecal, topical and via antibiotic-impregnated shunt catheters) on CSF-shunt infections in persons treated for hydrocephalus using internalised CSF shunts.
We conducted a systematic electronic search without restrictions on language, date or publication type. We performed the search on the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase, with the help of the Information Specialist of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group. The search was performed in January 2018.
All randomised and quasi-randomised controlled trials that studied the effect of antibiotic prophylaxis, in any dose or administration route, for the prevention of CSF-shunt infection in patients that were treated with an internal cerebrospinal fluid shunt. Patients with external shunts were not eligible.
Two review authors independently extracted data from included studies. We resolved disagreements by discussion or by referral to an independent researcher within our department when necessary. Analyses were also performed by at least two authors.
We included a total of 11 small randomised controlled trials, containing 1109 participants, in this systematic review. Three of these studies included solely children, and the remaining eight included participants of all ages. Most studies were limited to the evaluation of ventriculoperitoneal shunts. However, five studies included participants with ventriculoatrial shunts, of which one study contained four participants with a subduroperitoneal shunt. We judged four out of 11 (36%) trials at unclear risk of bias, while the remaining seven trials (64%) scored high risk of bias in one or more of the components assessed.We analysed all included studies in order to estimate the effect of antibiotic prophylaxis on the proportion of shunt infections regardless of administration route. Although the quality of evidence in these studies was low, there may be a positive effect of antibiotic prophylaxis on the number of participants who had shunt infections (RR 0.55, 95% CI 0.36 to 0.84), meaning a 55% reduction in the number of participants who had shunt infection compared with standard care or placebo.Within the different administration routes, only within intravenous administration of antibiotic prophylaxis there may be evidence of an effect on the risk of shunt infections (RR 0.55, 95% CI 0.33 to 0.90). However, this was the only route that contained more than two studies (8 studies; 797 participants). Evidence was uncertain for both, intrathecal administration of antibiotics (RR 0.73, 95% CI 0.28 to 1.93, 2 studies; 797 participants; low quality evidence) and antibiotic impregnated catheters (RR 0.36, 95% CI 0.10 to 1.24, 1 study; 110 participants; very low quality evidence) AUTHORS' CONCLUSIONS: Antibiotic prophylaxis may have a positive effect on lowering the number of participants who had shunt infections. However, the quality of included studies was low and the effect is not consistent within the different routes of administration that have been analysed. It is therefore uncertain whether prevention of shunt infection varies by different antibiotic agents, different administration routes, timing and doses; or by characteristics of patients, e.g. children and adults. The results of the review should be seen as hypothesis-generating rather than definitive, and the results should be confirmed in adequately powered trials or large multicentre studies in order to obtain high-quality evidence in the field of ventricular shunt infection prevention.
脑脊液分流手术的主要并发症是分流感染。预防这些分流感染包括围手术期使用抗生素，抗生素可通过五种不同方式给药：口服；静脉注射；鞘内注射；局部应用；以及通过植入含抗生素的分流导管。
确定不同抗生素预防途径（即口服、静脉注射、鞘内注射、局部应用和通过含抗生素的分流导管）对使用内置脑脊液分流器治疗脑积水患者脑脊液分流感染的影响。
我们进行了系统的电子检索，对语言、日期或出版类型没有限制。在Cochrane多发性硬化症和中枢神经系统罕见病小组的信息专家的帮助下，我们在Cochrane图书馆的Cochrane对照试验中心注册库（CENTRAL）、MEDLINE和Embase上进行了检索。检索于2018年1月进行。
所有随机和半随机对照试验，研究了任何剂量或给药途径的抗生素预防对接受内部脑脊液分流治疗的患者预防脑脊液分流感染的效果。外部分流患者不符合条件。
两位综述作者独立从纳入研究中提取数据。如有分歧，我们通过讨论解决，必要时转介给我们部门的独立研究人员。分析也由至少两位作者进行。
在本系统评价中，我们共纳入了11项小型随机对照试验，包含1109名参与者。其中三项研究仅纳入儿童，其余八项纳入了所有年龄段的参与者。大多数研究仅限于评估脑室腹腔分流术。然而，五项研究纳入了脑室心房分流术的参与者，其中一项研究包含四名硬膜下腹腔分流术参与者。我们判断11项试验中有4项（36%）的偏倚风险不明确，而其余7项试验（64%）在评估的一个或多个方面得分高偏倚风险。我们分析了所有纳入研究，以估计抗生素预防对分流感染比例的影响，无论给药途径如何。尽管这些研究中的证据质量较低，但抗生素预防可能对发生分流感染的参与者数量有积极影响（风险比0.55，95%置信区间0.36至0.84），这意味着与标准护理或安慰剂相比，发生分流感染的参与者数量减少了55%。在不同给药途径中，只有在静脉注射抗生素预防时，可能有证据表明对分流感染风险有影响（风险比0.55，95%置信区间0.33至0.90）。然而，这是唯一包含两项以上研究的途径（8项研究；797名参与者）。抗生素鞘内注射（风险比0.73，95%置信区间0.28至1.93，2项研究；797名参与者；低质量证据）和含抗生素导管（风险比0.36，95%置信区间0.10至1.24，1项研究；110名参与者；极低质量证据）的证据均不确定。
抗生素预防可能对降低发生分流感染的参与者数量有积极影响。然而，纳入研究的质量较低，且在已分析的不同给药途径中效果不一致。因此，尚不确定分流感染的预防是否因不同的抗生素、不同的给药途径、时间和剂量而异；或因患者特征（如儿童和成人）而异。本综述的结果应视为产生假设而非确定性结果，结果应在有足够效力的试验或大型多中心研究中得到证实，以便在脑室分流感染预防领域获得高质量证据。
