Antibiotic prophylaxis for surgical introduction of intracranial ventricular shunts.

BACKGROUND: Systemic antibiotics and antibiotic-impregnated shunt systems are often used to prevent shunt infection.

OBJECTIVES: To evaluate the effectiveness of either prophylactic systemic antibiotics or antibiotic-impregnated shunt systems for preventing infection in patients who underwent surgical introduction of intracranial ventricular shunts.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and the meeting proceedings from the American Association of Neurological Surgeons and from the European Association of Neurosurgical Societies, until June 2005.

SELECTION CRITERIA: We included randomized or quasi-randomized controlled trials comparing the use of prophylactic antibiotics (either systemic or antibiotic-impregnated shunt systems) in intracranial ventricular shunt procedures with placebo or no antibiotics.

DATA COLLECTION AND ANALYSIS: Two authors appraised quality and extracted data independently.

MAIN RESULTS: We included seventeen trials with overall 2134 participants. We performed two separate meta-analyses: one that evaluated the use of systemic prophylactic antibiotics and another that evaluated the use of antibiotic-impregnated systems. All studies included shunt infection in their primary outcome. We could not analyse all-cause mortality regarding systemic antibiotics due to lack of data. No significant differences were found (odds ratio (OR): 1.47, 95% confidence intervals (CI) 0.83 to 2.62) for this outcome regarding the use of antibiotic-impregnated catheters compared with standard ones. The use of systemic antibiotic prophylaxis and the use of antibiotic-impregnated catheters were associated with a decrease in shunt infection (OR: 0.52, 95% CI 0.36 to 0.74 and OR: 0.21, 95% CI 0.08 to 0.55 respectively). We found no significant benefit for shunt revision in both meta-analyses that evaluated systemic antibiotics and impregnated-shunt systems. We found no significant differences between the subgroups evaluated: type of shunt (internal/external, ventriculoperitoneal/ventriculoatrial), age and duration of the administration of antibiotics.

AUTHORS' CONCLUSIONS: We could demonstrate a benefit of systemic prophylactic antibiotics for the first 24 hours postoperatively to prevent shunt infection, regardless of the patient's age and the type of internal shunt used. The benefit of its use after this period remains uncertain. However this data derives from the rate of shunt infection, which is an intermediary outcome. Future trials should evaluate the effectiveness of different regimens of systemic antibiotics rather than placebo, and should include all-cause mortality, shunt revision and adverse events as additional outcomes. Evidence suggests that antibiotic-impregnated catheters reduce the incidence of shunt infection although more well-designed clinical trials testing the effect of antibiotic-impregnated shunts are required to confirm their net benefit.