Table 2.
Prevention Studies Reporting Incidence
| First Author, Year; Study; Period; Country; Reference | Device | Catheter Type | Hand Hygiene Enhanced; Hand Hygiene Compliance Monitoring; Educational Program and/or Checklist | Item(s) Related to Insertion | Items Related to Manipulation | Routine Catheter Exchange; Catheter Removal | VM Rate Before/CG | VM Rate After/IG | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Antibiotic Prophylaxis; Patient Skin Antisepsis | Head Hair Management | SC Tunneling; Length | Other | Aseptic Management | Dressing Change; Type | CSF Sampling Frequency | Other | |||||||
| Walek; 2021; Retrospective; 2007-2019; USA;103 | EVD | Plain; AIC only after suspected or proven VM | Yes; yes; yes | No; yes | Clipping | Yes; NA | Sterile implantation; all OR doors closed strategy | Yes | No dressing, unless oozing from site | Only if suspected VM | Aseptic management of unintended disconnection; aseptic change of full collection reservoir | No; as soon as possible | 6.7 /1000 EVD days | 2/1000 EVD days* |
| Thien; 2019; Prospective, following retrospective audit; 2014-16; USA;104 | EVD | Plain, SIC, and AIC | NS; no; no | Single dose before; scrub with Hexodane followed by Cetrimide 1% and povidone iodine | At least ¼ head shave | Yes; ≥5cm | Double gloves and change outer glove before handling EVD | Yes | Elective change at 4 days; plain | According to the level of suspicion | EVD clamped when handled or patient is mobilized; drainage bag changed when ¾ full | Optional if colonized or after 21 days; within 10 days if feasible | 4.8% | 2% |
| Yang Li; 2019; prospective; 2016-18 China;105 | EVD | NS | Yes; no; yes | Single dose before; CHX antisepsis | NS | NS | – | Yes | Changed every 2 days; NA | Every 2 days for culturing | Daily drainage bag emptying | NS | 5.48% | 2.62%* |
| Ates; 2020; before-after; 2011-13; Turkey;106 | VPS | AIC | Yes; yes; yes | Yes; CHX antisepsis | Shave | By definition; NA | OR doors closed | Yes | Changed 48 hours later; NS | NA | NA | NA | 6.8% | 2,6%* |
| Whyte; 2020; before-after; 2014-15 and 2017; USA;107 | EVD, SGD, SDD | NA | NS; NS; yes | Started before, <48-hour prophylaxis; | Clipping | NS | – | Yes | When loose or soiled; CHX- eluting | NS | – | NS | 5.5% | 5.6% |
| Hussein; 2019; before-after; 2014-17; Israel;28 | EVD, LD, ICP | NA | Yes; yes; yes | Yes, unspecified timing; NS | NS | NS | OR insertion for EVD, ICP | Yes | NS | Only if VM suspected | MDR-carriers’ cohorting; Daily catheter assessment | No; as soon as possible | 17.3/1000 catheter days | 9.2/1000 |
| Sweeny; 2019; Retrospective cohort; 2012-18; USA;108 | VPS | Plain | NS; NS; yes | Before and up to 24 hours; CHX antisepsis | NS | By definition; NA | CHX antisepsis 12h before operation; Limited traffic in OR Double gloves and change outer glove before handling hardware |
NS | NS | NA | NA | NA | 8.8% | 5.6% |
| Katzir; 2019; retrospective cohort; 2010-15; Israel;109 | EVD | AIC | NS; NS; NS | Single dose before; NS | NS | Yes; ≥5cm | OR insertion | Yes | Every 2 days; semi-occlusive adhesive | NA | NA | Every 5 days vs clinically indicated; NS | 32% | 8% |
| Mallucci; 2019; Single blinded RCT; 2013-17; UK/Ireland;85 | VP shunt | Plain vs AIC vs SIC | NS; NS; NS | Before was standard, further NS; NS | NS | NS | NS | NS | NS | NA | NA | NA | 6% | 2%* AIC/IG vs 6% SIC/IG |
| Roethlisberger; 2018; Single-blinded RCT Trial; 2013-16; Switzerland;110 | EVD | SIC | NS; NS; NS | Single-dose, before skin incision; yes | Hemicranial clipping | 5cm | OR indertion | NS | If bleeding 12hs post-operation or every 5 days; non-CHX-adhesive (CG) vs CHX-containing (IG) | NS | Dressing edges secured by surgical stapler | NS | 26% | 14%# |
| Omrani; 2018; Retrospective cohort; 2009-15; UK;111 | VPS, VAS, VpS | AIC | NS; NS; Yes | Yes; Povidone iodine scrub | Clipping | By definition; NA | OR insertion; Restricted access; Double glove changed before assembling shunt and inserting ventricular catheter | NS | NS | NA | NS | NA | 5.43% | 3.27% |
| Ershova;, 2018; Prospective; 2011-16; Russia;112 | EVD | NS | Yes; yes; yes | Single anesthesia induction dose; CHX antisepsis | NS | NS | Sterile implantation, only by clear indications | Yes | NS | NS | Minimization of disconnections | No; as soon as possible | 22.2 cases per 1000 EVD days | 13.5 cases per 1000 EVD days |
| Bashir; 2016; Retrospective; 2003-9; Denmark;113 | VPS | Plain | NS; NS; NS | Vancomycin, 980mg IV and 20mg IVT before; CHX antisepsis | Shaving | By definition; NA | Limited traffic in the OR; Glove change before shunt handling | NS | NS | NA | NA | NA | 11.8% | 9.8% |
| Chatzi; 2014; before-after; Greece;101 | EVD | Plain | Yes; yes; yes | 30 minutes prior to and 6–8 hr after insertion | Shaving | Yes; ≥5cm | OR insertion | Yes | Daily; plain | If clinically indicated | EVD unblocking was avoided or, otherwise, performed distally | Aiming at 7th drainage day; as soon as possible | 28% | 10.5%* |
| Camacho; 2013; before-after; 2007-10; Brasil;114 | EVD | NA | Yes; yes; yes | Before and up to 24 hours post-insertion; CHX antisepsis | Whole scalp clipping | 5cm | OR insertion; semirecumbent position; | Yes | Daily dressing changes and head wrapping by neurosurgery residents | Only when infection is suspected | Avoidance of catheter unblocking | No; If the system integrity is violated or as soon as possible | 9.5% | 4.8% |
| Flint; 2013; retrospective before-after; 2005-7 and 2009-11; USA;115 | EVD | Plain (before), AIC (after) | Yes;NS; yes | Single dose before; CHX antisepsis | Broad clipping | 3–5cm | ICU insertion; all staff in room wore mask and cap; full draping of patient’s head and body; | Yes, strict technique | No routine change; adherent transparent dressing | On clinical indication | Manipulation steps: a) all staff in room wore mask and cap; b) 3-way stopcock positioned at 45°, b) stopcock and adjacent tubing submerged into isopropyl alcohol, c) the physician wears sterile gloves and gown, d) rubbed with CHX, e) port opened and cap discarded, f) inner port repeatedly rubbed with CHX, g) saline rinsing, h) CSF sampling or flush, i) new, sterile cap placed | No; NS | 6.3% | 0.8%* |
| Kubilay; 2013; prospective; 2006-12; USA;116 | EVD | AIC | Yes; no; yes (nurse monitoring at bedside) | Before and up to 24 hours; iodine povacrylex and isopropyl alcohol antisepsis | Clipping | NS | Compliance monitoring by the patient’s bedside nurse | Yes | NS | N | NA | NS | 9.2% | 0% |
| Lwin; 2012; Prospective, 3-phased audit; 2007-8; Singapore;117 | EVD | Plain initially and SIC during the last phase | Yes; yes; yes | NS; NS | NS | NS | Limiting the number of personnel in the OR and minimising the duration of the operation | Yes | NS | When VM was suspected | – | Within 10 days; as soon as possible | 6.1% | 0% |
| Kestle; 2011; Prospective; 2007-9; USA;118 | VPS, VAS, VpS | Non-AIC | Yes; yes; yes | A dose before and a second dose following operation; CHX antisepsis | Clipping | By definition; NA | Limited traffic in the OR; Patient position of the OR site away from door | NS | NS | NA | – | NA | 8.8% | 5.7%* |
| Williams; 2011; before-after; 2005-7; Australia;119 | EVD | NS | NS; NS; NS | NS; CHX antisepsis | Clipped or shaved only around bur hole | No | – | Yes | Every 3 days; plain transparent | Daily vs every 3 days | Unblocking by saline with sterile gloves and aseptic technique | NS | 17% | 10.8%* |
Notes: *denotes significant reduction; #denotes nonsignificant VM reduction ; however, the bacterialregrowth at the catheter exit site was significantly decreased.
Abbreviations: AIC, antibiotic-impregnated catheter; CG, control group; CHX, chlorhexidine; CSF, cerebrospinal fluid; EVD, external ventricular drain; ICP, intracranial pressure; ICU, intensive care unit; IG, intervention group; IV, intravenous; IVT, intraventricular; NA, not applicable; NS, not specified; OR, operating room; SIC, silver-impregnated catheter; UK, United Kingdom; USA, United States of America; VAS, ventriculoatrial shunt; VP, ventriculoperitoneal shunt; VpS, ventriculopleural shunt; VM, ventriculitis or postoperative meningitis or healthcare-associated ventriculitis and meningitis.