Treatment and prevention of infections of cerebrospinal fluid shunts.

The etiology, pathogenesis, clinical manifestations, diagnosis, and treatment of cerebrospinal fluid (CSF) shunt infections are reviewed. Infection is a frequent complication of neurosurgical procedures performed for the treatment of hydrocephalus. Shunt infections generally occur within the first two months after surgery. Staphylococcus epidermidis is the most common cause of infections of both ventriculoatrial and ventriculoperitoneal shunts. The preferred treatment of CSF shunt infections involves intravenous antimicrobial therapy, surgical removal of the infected shunt, installation of an extraventricular drainage device, and placement of a new shunt once the CSF is sterile. However, many aspects of therapy are controversial because few controlled, comparative studies have been reported. Intravenous vancomycin is the drug of choice for empiric treatment of shunt infections. Nafcillin is recommended for infections caused by methicillin-sensitive strains of staphylococci. Vancomycin should be used for infections caused by methicillin-resistant strains of staphylococci or in patients who are allergic to penicillin. The addition of rifampin has eradicated infections that failed to respond to monotherapy with vancomycin or nafcillin. Intraventricular antimicrobial therapy is indicated if the risks associated with surgery are high or if ventriculitis is persistent and refractory to systemic antimicrobial therapy. The role of prophylactic antimicrobial therapy is controversial. Infection continues to be an important complication of CSF shunt placement; many aspects of treatment are controversial.