Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 7: Antibiotic-impregnated shunt systems versus conventional shunts in children: a systematic review and meta-analysis

Abstract

Object: The objective of this systematic review and meta-analysis was to answer the following question: Are antibiotic-impregnated shunts (AISs) superior to standard shunts (SSs) at reducing the risk of shunt infection in pediatric patients with hydrocephalus?

Methods: Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to AIS use in children. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was assembled summarizing the studies and the quality of their evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using the chi-square and I(2) statistics. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

Results: Six studies, all Class III, met our inclusion criteria. All but one study focused on a retrospective cohort and all but one were conducted at a single institution. Four of the studies failed to demonstrate a lowered infection rate with the use of an AIS. However, when the data from individual studies were pooled together, the infection rate in the AIS group was 5.5% compared with 8.6% in the SS group. Using a random-effects model, the cumulative RR was 0.51 (95% CI 0.29-0.89, p < 0.001), indicating that a shunt infection was 1.96 times more likely in patients who received an SS.

Conclusions: We recommend AIS tubing because of the associated lower risk of shunt infection compared to the use of conventional silicone hardware (quality of evidence: Class III; strength of recommendation: Level III).

Recommendation: Antibiotic-impregnated shunt (AIS) tubing may be associated with a lower risk of shunt infection compared with conventional silicone hardware and thus is an option for children who require placement of a shunt.

Strength of recommendation: Level III, unclear degree of clinical certainty.

Keywords: AANS = American Association of Neurological Surgeons; AIS = antibiotic-impregnated shunt; CNS = Congress of Neurological Surgeons; RR = risk ratio; SS = standard shunt; antibiotic-impregnated shunt; cerebrospinal fluid; hydrocephalus; infection; meta-analysis; pediatric patient; practice guidelines; shunt.