ANALISIS JURNAL

HIDROSEFALUS

KEPERAWATAN ANAK 1

Kelompok 11

Mega Marya Ulfah 1610913220009

Prinandita Syafira 1810913220017

Novita Sari 1610913320032

Nuarita dewi lestari 1810913320011

Ni Made Dwi Armawati 1810913320013

Nur khalisah hayati 1810913220011

Tio Yulia Margaretha 1810913320012

PROGRAM STUDI ILMU KEPERAWATAN

FAKULTAS KEDOKTERAN
UNIVERSITAS LAMBUNG MANGKURAT
BANJARBARU
2020
KATA PENGANTAR

Bismilahirahmanirahim,
Puji dan syukur kami panjatkan kehadirat Tuhan Yang Maha Esa, Syukur Alhamdulillah,
merupakan satu kata yang sangat pantas penulis ucakan kepada Allah Swt, yang karena bimbingan-Nya lah
maka penulis bisa menyelesaikan sebuah analisis jurnal berjudul "HIDROSEFALUS”
Sholawat bernada salam kami sanjung sajikan kepada kepangkuan Nabi besar Muhammad SWT,
dengan adanya rasulullah, Alhamdulillah sampai saat ini kami dapat menyusun makalah ini. Saya
menyadari bahwa masih sangat banyak kekurangan yang mendasar pada makalah ini.
Oleh karna itu saya mengundang pembaca untuk memberikan kritik dan saran yangbersifat
membangun untuk kemajuan ilmu pengetahuan ini.

Banjarbaru, 23 maret 2020

Penulis,
 BAB I

PROFIL ARTIKEL JURNAL

A. Judul Artikel Jurnal

Prevention of infection by antibiotic-impregnated shunts after pediatric hydrocephalus
treatment: A single center, retrospective study in China
B. Pengarang
Bo Yang (MD, PhD), Yunhai Song (MD), Pingping Gao (MD), Nan Bao (MD, PhD)
C. Sumber
Journal Clinical Neurology and Neurosurgery
D. Tanggal Publikasi

17 Oktober 2016
 BAB II

ANALISIS JURNAL

Analisis PICO

PATIENT, PROBLEM, POPULATION :

 Infeksi berkembang sekitar 0,3% -12,9% pada pasien pasca operasi biasanya dalam
rentang 6 bulan setelah implantasi / operasi shunt. Pada penelitian ini tahun 2001
hingga 2013, tingkat infeksi dengan jangka waktu 6 bulan secara keseluruhan 3,47%
ini konsisten dengan pengalaman penelitian lain yang dipublikasikan rata-rata sekitar
11%, dan dapat mencapai setinggi 15-25% pada bayi dibawah dari 6 bulan.
 Hydrocephalus, salah satu penyakit neurologis pediatrik yang paling umum, paling
sering diobati dengan operasi shunt. Pasca bedah atau operasi, infeksi tetap menjadi
komplikasi umum dan penyebab utama kecacatan dan kematian. Sebagian besar
infeksi bakteri timbul dari kulit normal, yang paling sering stafilokokus koagulase
negatif (Staphylococcus epidermidis dan aureus), dan bakteri Gram-negatif (E. coli),
yang masuk dalam kateter shunt atau kompartemen cairan serebrospinal diwaktu
pemasangan kateter atau melalui kontaminasi selama prosedur bedah. Selain itu,
tingkat infeksi shunt bisa dipengaruhi oleh kondisi fisik anak, keberadaan kulit
masalah, dan teknik bedah, waktu, komplikasi termasuk pendarahan.
 Penelitian dilakukan pada tahun 2001 hingga 2013 dengan 807 kasus anak mengalami
hydrocephalus dengan operasi shunt yang dilakukan oleh ahli bedah yang sama di
Departemen Neurosurgery di Medikal Center Anak Shanghai berafiliasi ke Shanghai
Jiaotong University School of Medicine. . Sebagian besar kasus (736/807) adalah bayi
berusia dibawah 1 tahun. Berdasarkan 807 kasus operasi shunt, 28 anak positif
terinfeksi mikroorganisme selama rentang waktu 6 bulan pasca operasi.

INTERVENSI :

 Protokol penelitian telah disetujui oleh Institutional Review Board dari Medikal
Center Anak Shanghai, dan mematuhi prinsip-prinsip yang ditetapkan dalam US Code
of Federal Regulations tentang Perlindungan Subyek Manusia, direvisi 15 Januari
2009 serta mematuhi Dunia Medical Association Deklarasi Helsinki.
 Pemilihan katup shunt diputuskan berdasarkan status ekonomi keluarga dan
keparahan hidrosefalus dengan konsultasi antara pasien keluarga dan ahli bedah. 303
 kasus menerima kateter konvensional dan 504 kasus menerima AIS.
 Satu hari sebelum operasi, pasien harus mandi dan keramas terlebih dahulu. Lalu
mereka diberi sefalosin secara intravena sebanyak 50 mg/kg 30 menit sebelum operasi
(apabila alergi dengan sefalosprin maka diganti dengan makrolida atau penisilin).
Rambut anak di cukur di bagian bawah yang akan di bedah dan mereka diposisikan
secara telentang dengan kepala dimiringkan. Ahli bedah membuat sayatan sebagai
lubang untuk memasukkan kateter yang hendak ditanam pada ventrikel (tepatnya pada
ujung posterior lateral kiri ventrikel di lobus oksipital)
 Berdasarkan hasil penelitian, dari 28 anak yang terkena infeksi mikroorganisme. 10
anak menggunakan kateter Antibiotik-impragnated shunts (AIS) dan 18 orang
menggunakan kateter konvensional. Di dapatkan hasil bahwa tingkat kemunculan
infeksi lebih rendah atau lamban waktunya untuk AIS daripada kateter konvensional.
Karena Secara umum, AIS dilapisi dengan rifampisin dan klindamisin yang efektif
terhadap patogen. Eksperimen in vitro ini menunjukkan bahwa kateter AIS dapat
membunuh semua bakteri dalam waktu 48-52 jam dengan efek farmakologis yang
bertahan selama 2 bulan. Bahkan jika efeknya menghilang kemungkinan infeksi
sebelumnya tidak meningkat yang mengindikasikan efek bakterisidal dari AIS kateter
lebih kuat dari efek penghambatannya. Selain lebih relatif rendah terhadap
pencegahan infeksi, kateter AIS relatif lebih murah. Di Cina (yang digunakan dalam
penelitian ini), ketika katup shunt yang sama digunakan, harga kateter AIS setara
dengan sekitar 200 dolar AS dan harga kateter konvensional berkisar 40 dolar AS.
Total biaya terkait dengan operasi kateter AIS adalah sekitar RMB 50.000 yuan, RMB
12.000 yuan lebih dari untuk kateter konvensional. Namun, penghematannya
diperoleh melalui pencegahan infeksi dari kateter AIS karena resiko kateter
konventional shunt harus diangkat setelah infeksi, ditempatkan untuk drainase, dan di
setidaknya 2 minggu untuk diberi antibiotik sensitif atau desinfeksi dan kemudian
dimasukkan dengan perangkat shunt baru. Jika hal ini terjadi, untuk pemasangan
kembali kateter melebihi RMB 150.000 yuan, jauh lebih tinggi daripada biaya
tambahan kateter AIS.

COMPARE :

Jurnal : Prevention of infection by antibiotic-impregnated shunts after pediatric

hydrocephalus treatment: A single center, retrospective study in China

 Protokol penelitian telah disetujui oleh Institutional Review Board dari Medikal
Center Anak Shanghai, dan mematuhi prinsip-prinsip yang ditetapkan dalam US Code
 of Federal Regulations tentang Perlindungan Subyek Manusia. Pemilihan katup shunt
diputuskan berdasarkan status ekonomi keluarga dan keparahan hidrosefalus dengan
konsultasi antara pasien keluarga dan ahli bedah. 303 kasus menerima kateter
konvensional dan 504 kasus menerima AIS.
 Berdasarkan hasil penelitian, dari 28 anak yang terkena infeksi mikroorganisme, di
dapatkan hasil bahwa tingkat kemunculan infeksi lebih rendah atau lamban waktunya
untuk AIS daripada kateter konvensional. Karena Secara umum, AIS dilapisi dengan
rifampisin dan klindamisin yang efektif terhadap patogen. Eksperimen in vitro ini
menunjukkan bahwa kateter AIS dapat membunuh semua bakteri dalam waktu 48-52
jam dengan efek farmakologis yang bertahan selama 2 bulan. Bahkan jika efeknya
menghilang kemungkinan infeksi sebelumnya tidak meningkat yang mengindikasikan
efek bakterisidal dari AIS kateter lebih kuat dari efek penghambatannya.

Jurnal : Antimicrobial-impregnated and - coated shunt catheters for prevention of

infections in patients with hydrocephalus: a systematic review and meta-analysis

 Dalam penelitian ini digunakan metode strategi pencarian, pilihan studi, dan ekstraksi
data. Dua peneliti melakukan pencarian sistematis terhadap database elektronik
PubMed dan Scopus menggunakan istilah pencarian yaitu antibiotik atau antimikroba
dan cairan serebrospinal atau ventrikuloperitoneal serta drainase ventrikel eksternal
dan juga shunt atau kateter dan infeksi. Kedua penyelidik melakukan pencarian
literatur yang terpisah dan independen dan mengekstraksi data yang relevan. Jika
perbedaan terjadi, mereka diselesaikan dalam pertemuan dengan simpatisan ketiga.
Akhir pencarian dilakukan pada Januari 2014. Tidak ada batasan tahun publikasi.
Data yang diekstraksi termasuk desain penelitian, wilayah geografis, jeni kateter,
durasi tindak lanjut periode, pendanaan, karakteristik populasi, jenis prosedur bedah
saraf, dan hasil (infeksi, kematian).
 Berdasarkan penelitian, risiko lebih rendah untuk infeksi diamati ketika AIC berada
dibandingkan dengan Silver-coated (CCs) untuk semua jenis implantasi kateter CSF
Analisis subkelompok menunjukkan bahwa AIC dikaitkan dengan risiko lebih rendah
untuk operasi shunt atau ventrikel drainase, infeksi dini pada operasi shunt permanen,
atau infeksi muncul dalam jangka waktu yang lambat pada operasi shunt permanen.
Perkembangan infeksi shunt CSF juga lebih rendah dengan AIC daripada dengan
Silver-coated (CCs). Akhirnya, tidak ada perbedaan yang diamati ketika kateter
 dilapisi rifampin-minocyclin dibandingkan dengan rifampin-klindamisin dah tidak
ada pula perbedaan yang diamati pada risiko infeksi karena Staphylococcusspp.
(terlepas dari jenis shunting), CoNS, S. aureus, atau bakteri gram positif, tetapi
risikonya lebih tinggi untuk infeksi karena bakteri gram negatif, nonstaphylococcal
spesies, dan MRSA

OUTCOME :

 Berdasarkan hasil penelitian pada jurnal ini, terbukti dalam pengalaman pusat tunggal
bahwa penggunaan kateter Antibiotik-impragnated Shunt, relatif murah dan dapat
mengurangi tingkat infeksi dibandingkan dengan kateter shunt konvesional, untuk
pengobatan hidrosefalus pediatrik dikaitkan dengan tingkat infeksi secara signifikan
lebih rendah dengan tindak lanjut 6 bulan, terutama dalam 1 bulan tindak lanjut, yang
berarti dapat mengurangi biaya.

Kekurangan dan Kelebihan Jurnal

 Kelebihan jurnal:

1. Dalam jurnal sudah di jelaskan Prosedur dan Perawatan Bedah pada Anak
2. Di dalam jurnal sudah dijelaskan Penilaian Infeksi Shunt secara jelas
 Kekurangan jurnal:
1. Tidak ada metode secara jelas
2. Tidak ada analisis dan perbandingan jenis hidrosefalus komplikasi dengan pusat lainnya.
Implementasi keperawatan

Hydrocephalus, salah satu penyakit neurologis pediatrik yang paling umum, paling sering diobati
dengan operasi shunt. infeksi shunt pasca operasi tetap menjadi komplikasi utama yang tidak hanya secara
serius mempengaruhi kelangsungan hidup dan kualitas hidup tetapi juga merupakan beban ekonomi yang
berat untuk keluarga pasien. Dalam analisis retrospektif pusat tunggal anak-anak dengan hidrosefalus, AIS
relatif terhadap penggunaan kateter konvensional untuk operasi shunt yang dikaitkan dengan tingkat infeksi
yang secara signifikan lebih rendah selama 6 bulan tindak lanjut, yang terutama ditentukan oleh tingkat
signifikan lebih rendah pada tindak lanjut 1 bulan.

Sebagian besar infeksi shunt bakteri timbul dari kulit normal, Yang paling sering stafilokokus
koagulase negatif (Staphylococcus epidermidis dan aureus), dan bakteri Gram-negatif (E. coli), yang masuk
dalam kateter shunt atau kompartemen cairan serebrospinal diwaktu pemasangan kateter atau melalui
kontaminasi selama prosedur bedah.Kebanyakan shunt terinfeksi secara intraoperatif, dengan infeksi
bermanifestasi dalam waktu satu tahun pada lebih dari 90% pasien, sebagian besar di dalam 6 bulan. Oleh
karena itu pendekatan lain untuk mencegah dan mengobati infeksi shunt melibatkan penggunaan bahan
antibakteri pada shunt untuk membunuh bakteri idealnya dalam waktu satu bulan. Disinfeksi bedah yang
ketat dan lingkungan ruang operasi yang dioptimalkan mengurangi tingkat infeksi shunt hingga 1% atau
kurang.

Saat ini, kateter shunt diresapi dengan antibiotik adalah kateter shunt yang paling banyak
digunakan; mereka yang ada di masa sekarang. Secara umum, antibiotik diresapi dengan rifampisin dan
klindamisin yang efektif terhadap stafilokokus patogen. Eksperimen in vitro menunjukkan bahwa kateter
AIS dapat membunuh semua bakteri dalam waktu 48-52 jam dengan efek farmakologis yang bertahan
selama 2 bulan. Bahkan jika efeknya menghilang kemungkinan infeksi sebelumnya tidak meningkat yang
mengindikasikan efek bakterisidal dari AIS kateter lebih kuat dari efek penghambatannya.

Dalam pengalaman pusat tunggal ini, penggunaan Antibiotik-impragnated shunts relatif murah dan
mengurangi tingkat infeksi dibandingkan kateter shunt konvensional, untuk pengobatan hidrosefalus
pediatrik dikaitkan dengan tingkat infeksi secara signifikan lebih rendah pada 6 bulan masa tindak lanjut,
terutama dalam 1 bulan tindak lanjut, yang berarti pengurangan biaya

BAB III

PENUTUP
Kesimpulan

Hydrocephalus, salah satu penyakit neurologis pediatrik yang paling umum, paling sering diobati dengan
operasi shunt. Pasca bedah atau operasi, infeksi tetap menjadi komplikasi umum dan penyebab utama
kecacatan dan kematian, berkembang pada 0,3% -12,9% dari pasien biasanya dalam 6 bulan setelah
implantasi / operasi shunt.

Dalam pengalaman pusat tunggal ini, penggunaan Antibiotik-impragnated shunts relatif murah dan
mengurangi tingkat infeksi dibandingkan kateter shunt konvensional, untuk pengobatan hidrosefalus
pediatrik dikaitkan dengan tingkat infeksi secara signifikan lebih rendah pada 6 bulan masa tindak lanjut,
terutama dalam 1 bulan tindak lanjut, yang berarti pengurangan biaya

Saran

Penilitian lebih lanjut di perlukan untuk memperkecil kemungkinan infeksi yang mungkin terjadi akibat
prosedur yang dilakukan (implantasi atau operasi shunt), dan di harapkan agar harganya dapat lebih murah
lagi agar dapat di pakai oleh kalangan menengah kebawah.
LAMPIRAN

Clinical Neurology and Neurosurgery 151 (2016) 92–95

Contents lists available at ScienceDirect

 Clinical Neurology and Neurosurgery

journalhomepage:www.elsevier.com/locate/clineuro

Prevention of infection by antibiotic-impregnated shunts after pediatric

hydrocephalus treatment: A single center, retrospective study in China
∗
Bo Yang (MD, PhD), Yunhai Song (MD), Pingping Gao (MD), Nan Bao (MD, PhD)

abstract

Objective: To investigate infection prevention by antibiotic-impregnated shunts (AIS) relative to conven-tional ones after pediatric hydrocephalus treatment.

Methods: This single center, retrospective analysis comprised 807 consecutive pediatric cases of hydro-cephalus shunting performed by the same neurosurgeon between January 2001
and February 2013. Conventional and AIS catheters were used in 303 and 504 cases, respectively. Study outcomes were infection rates at 6 months (primary), and at 1 month and
between 1 and 6 months (secondary). An infant (<1 year) subgroup was also analyzed.

Results: The AIS relative to the conventional catheter group had significantly lower infection rates at

6 months (1.98% [10/504] vs. 5.95% [18/303], two-tailed p = 0.0046; central nervous system: 60% and

55.56%; abdominal: 20% and 27.77%; wound: 20% and 16.67%, respectively) and 1 month (0.19% [1/504] vs. 2.65% [8/303], p = 0.0023, respectively), but statistically similar rates
between 1 and 6 months (1.79% [9/504] vs. 3.30% [10/303], p = 0.2296, respectively). In the infant subgroup, AIS application was also associated with reduction in shunt infection
(1.49% [7/470] vs. 3.76% [10/266], p = 0.0489, respectively). Conclusion: AIS as compared to conventional catheter use appears to lower infection risk at 6 months, mainly during the
first month, after hydrocephalus therapy in children.

© 2016 Elsevier B.V. All rights reserved

1. Introduction

Hydrocephalus, one of the most common pediatric neurolog-ical diseases, is most often treated with shunt surgery. Infection, which remains a common
complication and the main cause of postsurgical disability and mortality, develops in 0.3%–12.9% of patients [1,12], usually within 6 months after shunt
implanta-tion. Antibiotic-impregnated shunt (AIS) catheters with in vitro antimicrobial activity for up to 2 months were introduced to min-imize postoperative
infection, however, reported clinical results have been inconsistent [14,15]. The present retrospective analysis of data gathered at our hospital over 12 years
therefore com-pared infection rates at the highest risk window of up to 6 months follow-up between 504 and 303 children with hydrocephalus who underwent
treatment with AIS and conventional shunt catheters, respectively.

2. Materials and methods

2.1. General information

The study protocol was approved by the Institutional Review Board of Shanghai Children’s Medical Center, and adheres to the principles set forth in the US Code
of Federal Regulations, Title 45, Part 46, Protection of Human Subjects, revised January 15, 2009 and the World Medical Association Declaration of Helsinki. All
patient’s parents provided written informed consent before the procedures.

Between January 2001 and February 2013, 807 consecutive children with hydrocephalus were treated with shunt surgery performed by the same neurosurgeon at
the Department of Neuro-surgery of Shanghai Children’s Medical Center affiliated to Shanghai Jiaotong University School of Medicine. Shunt valve choice was
decided mainly based on the family’s economic status and on hydrocephalus severity and in consultation between the patient’s family and the surgeon: 303 cases
received conventional catheters (from Aesculap and Johnson & Johnson), and 504 cases received AIS (Johnson & Johnson AIS catheters, and including Johnson
& John-
 B. Yang et al. / Clinical Neurology and Neurosurgery 151 (2016) 92–95
son or Aesculap valves). The follow-up period extended to at least 6 months.
2.2. Surgical procedure and treatment
One day before surgery, children were bathed and their hair washed, and
30 min before surgery, 50 mg/kg body weight of a second-generation
cephalosporin was administered intra-venously; macrolides or penicillins
were used in those allergic to cephalosporins. Children’s hair was shaved off
under surgical field, and they were placed in the supine position, with head
tilted and neck and shoulder padded. The posterior horn of the left lateral
ventricle at the occipital lobe was punctured. For children with non-
symmetric expansion of one lateral ventricle, the expanded side was
punctured. Before use, the shunt was rinsed and soaked in antibiotic solution,
the shunt valve was placed at the subcuta-neous pedicle of the postauricular
flap, and the remote catheter was led though a small incision below the
xiphoid using a subcu-taneous tunneler sheath. After surgery, antibiotics that
had been used before surgery were administered routinely for 3 days, and the
patient was discharged 7 days later after suture removal.
2.3. Assessment of shunt infection
All parents were advised to bring back their children to the same hospital
for any complications and follow-up. Children were diagnosed with shunt
infection if they developed: 1. symptoms of acute bacterial meningitis or
abdominal infection, such as fever, vomiting, lethargy, abdominal distension,
abdominal pain, loss of appetite, and difficulty feeding; 2. signs of local
infection in the shunt catheter region, such as skin irritation and ulceration;
and/or at least one of the following cerebrospinal fluid (CSF) findings: routine
6 aureus), and Gram-negative bacteria (E. coli), which enter the shunt catheter
CSF white blood cell (WBC) count >20 × 10 /L or red blood cell (RBC)-to-
WBC ratio <500/1; decreased CSF glucose concentra-tion and increased
protein concentration; and positive CSF bacterial cultures.
2.4. Statistical analysis
Continuous data are expressed as mean ± standard deviation and were
compared using the Student’s t-test, while categorical data are expressed as
number and percentage and were compared using the chi-square test (SPSS
v22, IBM, USA). A two-tailed p value < 0.05 was considered statistically
significant.
3. Results
Mean age was 17.1 months (range 3 months-4 years), and 13.7 months
(range, 1 month-3.2 years) for AIS and conven-tional shunt catheter groups,
respectively. Most of the cases (736/807) were infants younger than 1 year
old. Overall, of the 807 children with hydrocephalus who underwent shunt
surgery, 28 (3.47%) developed shunt infection during 6-month follow-up.
Clinical data of infected cases were included in Tables 1 and 2. Infection rate
was significantly lower in the AIS than conven-tional shunt catheter group at
6 months (1.98% [10/504] vs. 5.95% [18/303]; p < 0.0001), which also was
the case at 1 month (0.19% [1/504] vs. 2.65% [8/303]; p = 0.0014); however,
infection rates were statistically similar between 1 and 6 months (1.79%
[9/504] vs. 3.30% [10/303]; p = 0.2296) follow-up. Age distribu-tion was
similar (ranges, 3–48 and 2–38 months) but weight was lower (6.06 ± 1.84%
vs. 9.34 + 4.18%, p = 0.004) among children who developed infections
(central nervous system: 60% and 55.56%; abdominal: 20% and 27.77%;
wound: 20% and 16.67%, respectively) in the AIS group as compared to the
conventional catheter group.
93
In the subgroup of infants(<1 year), AIS application was also asso-ciated with
reduction in shunt infection (1.49% [7/470] vs. 3.76% [10/266], p = 0.0489,
respectively).
4. Discussion
In this single center retrospective analysis of children with hydrocephalus,
AIS relative to conventional catheter use for shunt surgery was associated
with significantly lower rates of infection throughout 6 months follow-up,
which was mainly determined by significantly lower rates at 1 month follow-
up.
Even after five decades of experience treating hydrocephalus with shunt
surgery, postsurgical shunt infection remains a major complication that not
only seriously affects survival and qual-ity of life but also represents a heavy
economic burden for the patient’s family. The overall 6-month infection rate
of 3.47% in the present study is consistent with published experience which
averages around 11%, and can reach as high as 15–25% in infants younger
than 6 months [1]. Beyond age, shunt infection rate can be influenced by the
child’s physical condition, presence of skin problems, and surgical techniques,
time, complications including hemorrhage, and number of staff present,
among others [2]. In the present study, the age and infection location
distributions were similar among children who developed infections in the two
groups studied, and all procedures were performed by the same neurosur-
geon.
Most bacterial shunt infections arise from normal skin flora, most
commonly coagulase-negative staphylococci (Staphylococcus epidermidis and
or cerebrospinal fluid compartment at the time of catheter insertion or through
contamination during the sur-gical procedure. The bacteria colonize the
catheter’s inner wall or surface and produce an extracellular mucus biofilm
that acts as a protective barrier against the body’s immune defenses and
antibi-otics. Over decades, several measures have been implemented to
prevent shunt infection. Rigorous surgical disinfection and an opti-mized
operating room environment reduced shunt infection rate to 1% or less [3].
Wide use of intravenous antibiotics was also advo-cated; however,
prophylactic antibiotic use remains controversial. For instance, second
generation cephalosporins have limited effect on infection prevention because
they cannot cross the blood-brain barrier and achieve an effective
concentration in the CSF compart-ment.
Most shunts are infected intraoperatively, with infection man-ifesting
within one year in over 90% of patients, most within 6 months. Another
approach to prevent and treat shunt infec-tion therefore involves use of
antibacterial materials on shunts to kill bacteria ideally within one month. Izci
et al. [4] employed silver coated catheters in patients with shunt infection and
signifi-cantly increased CSF protein level; three months later, CSF bacterial
cultures were negative and the protein level had dramatically decreased.
Currently, shunt catheters impregnated with antibiotics are the most widely
used shunt catheters; those in the present study were impregnated with
rifampicin and clindamycin which are effective against the most common
pathogenic staphylococci. In vitro experiments have shown that AIS catheters
can kill all bac-teria within 48–52 h with pharmacological effect maintained
for 2 months [5,6]. Even if the effect disappeared earlier chance of infec-tion
is not increased indicating that the bactericidal effect of AIS catheters is
stronger than their inhibitory effect [7].
Despite the strong bactericidal effect of AIS catheters, clinical study
results are inconsistent. In a review of 353 cases of chil-dren undergoing shunt
surgery, Sciubba et al. [8] reported a 2.4 fold lower infection rate for AIS than
conventional catheters (1.4% vs. 12%, respectively). A British multicenter,
retrospective study
94 B. Yang et al. / Clinical Neurology and Neurosurgery 151 (2016) 92–95

Table 1

Clinical and laboratory data of infected patients in AIS group.

Case Age/Sex Post-op Location CSF test Microorganism

Time

WBC Glu Protein

1 8 m/M 3m CNS H N H –

2 3 m/M 1m CNS H L H Staphylococcus aureus

3 5 m/M 3m CNS H L H Pseudomonas aeruginosa

4 10 m/F 4m CNS H N N –

5 4 m/M 2m CNS H L H Staphylococcus aureus

6 17 m/M 5m CNS H N H –

7 17 m/F 6m Abdomen N N N Staphylococcus epidermidis

8 24 m/M 3m Abdomen N N H –

9 9 m/M 2m Wounds H L H Staphylococcus aureus

10 19 m/F 5m Wounds H N H Staphylococcus epidermidis

m,months; H,high; L,low; N,normal

Table 2

Clinical and laboratory data of infected patients in conventional group.

Case Age/Sex Post-op Location CSF test Microorganism

Time

WBC Glu Protein

1 24 m/F 6m CNS H L H Staphylococcus epidermidis

2 4 m/M 1m CNS H L H –

3 2 m/F 1m CNS N L H Pseudomonas aeruginosa

4 3 m/M 1m CNS H L H –

5 12 m/M 3m CNS H N H Staphylococcus aureus

6 5 m/M 1m CNS H L H Escherichia coli

7 13 m/M 4m CNS H L H –

8 30 m/M 3m CNS H L H –

9 9 m/F 2m CNS H L H Staphylococcus aureus

10 2 m/F 1m CNS H N H –

11 1 m/M 1m Abdomen N N H Escherichia coli

12 16 m/M 3m Abdomen N L H –

13 9 m/F 5m Abdomen H N N Staphylococcus epidermidis

14 29 m/M 2m Abdomen N L N –

15 8 m/M 1m Abdomen H N H –
 16 24 m/F 4m Wounds
17 12 m/M 1m Wounds
18 14 m/F 2m Wounds
m,months; H,high; L,low; N,normal.
of 581 cases showed that AIS catheters significantly reduced the infection rate
after shunt surgery in children [9]. However, a sin-gle center study in
Germany including adult and pediatric patients reported similar postoperative
infection rate for AIS and conven-tional catheters, and AIS catheters had no
preventive effect on infection caused by skin ulceration or cerebrospinal fluid
leak-age [2]. Another retrospective analysis of pediatric hydrocephalus
performed in US reached similar conclusions [10]. A random-ized controlled
study recently performed in developing countries showed that although the
infection rate of AIS was numerically lower than that of ordinary catheters
(5% vs. 13.8%, respectively), the difference did not reach statistical
significance, which probably is a consequence of the small sample size.
However, cultured bacte-ria from the AIS catheters group were Gram-
negative strains, while those from the conventional catheters group were
Gram-positive Staphylococci, suggesting that AIS catheters presented
obvious antibacterial effect on staphylococci [11]. In a systematic review of
12 controlled studies on AIS and conventional catheters, includ-ing 5
pediatric studies with a total of 5613 shunt surgery cases, Parker et al. found
that AIS catheters yielded significantly reduced infection rates after shunt
surgery for both children (5.0% vs. 11.2%) and adults (3.3% vs. 7.2%; p <
0.0001) [12], coinciding with the con-clusions from another paper [13].
However, the authors pointed out that a prospective, randomized, large-scale
study is warranted. Consistent with the latter findings, the present
retrospective, single center, large scale study including 807 children showed
signifi-cantly lower postoperative infection rates for AIS than conventional
catheters throughout 6 months follow-up despite the designed drug efficacy
period of one month.
Although AIS catheters are widely used in Europe, the United States and
other developed countries, their use in developing coun-tries is restricted by
their cost. In Uganda, for example, the price of one shunt device donated by
an international society is less than 40 U.S. dollars, while the price of AIS
catheters similar to the ones used in the present study even when designed for
low-income coun-tries is as high as 400–500 U.S. dollars [11]. In China,
when the same shunt valves are used, the AIS catheters increase in cost to the
equivalent of approximately 200 U.S. dollars. However, the savings obtained
through infection prevention would more than offset the increased cost of AIS
catheters because shunt catheters must be removed after infection, placed for
drainage, and exposed for at least 2 weeks to sensitive or broad-spectrum
antibiotics, and then inserted with the new shunt device [11]. All treatments
and sur-gical procedures would not only increase mortality and morbidity, but
also medical costs by several fold. To this end, cost analysis of large samples
showed that for every 100 cases, use of AIS catheters in shunt surgery would
decrease death by 0.5 cases, hospital stay by 71 days, number of surgical
procedures by 11 fold, and hospitaliza-tion costs by 128,228 U.S. dollars [14].
At our hospital, total costs associated with AIS catheter surgery is about RMB
50,000 yuan, RMB 12,000 yuan more than for conventional catheters.
However, if infection arose in conventional catheters, the total cost for
removal,
drainage, disinfection and re-insertion of catheters exceeds RMB 150,000
yuan, much higher than the additional cost of AIS catheters.
The present study is limited, as are most reported related studies, by its
single center, retrospective design. However, its homogeneity derived from
the fact that all cases were from the same clinical center, all surgeries were
performed by one surgeon, and treatment regimens before and after surgery
includ-ing antibiotics were the same, avoided the confounding effect of
differences in surgeon’s clinical experience, medical environ-ment and
N L H Staphylococcus aureus
N N H –
H N H Staphylococcus epidermidis
treatment regimens of a multicenter study. However, a large, prospective,
double-blind, randomized, controlled study is warranted to confirm the
findings. In addition, no analysis and com-parison of type of hydrocephalus,
complication with other central nervous system disorders, cerebral
hemorrhage, or history of infec-tion were performed in this study, which
possibly also limits result reliability.
5. Conclusions
In this single center experience, use of antibiotic-impregnated shunt
catheters, relative to that of conventional shunt catheters, for the treatment of
pediatric hydrocephalus was associated with significantly lower rates of
infection by 6 months follow-up, mainly within 1 month follow-up, which
translates into reduced costs.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgement
The authors thank Dr. Roberto Patarca for critical review and language
modification of the manuscript
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