Infection of cerebrospinal fluid shunts in infants: a study of etiological factors

The aim of this study was to find reasons for the high incidence of cerebrospinal fluid shunt infections seen in neonates. Four-hundred sixty-six consecutive shunt operations were analyzed retrospectively in 294 children, and 60 children were studied prospectively by quantitative sampling of skin bacteria before surgery and by sampling open wounds, shunt catheters, surgical gloves, and airborne bacteria. In total, 110 strains of coagulase-negative Staphylococcus isolated from the skin of 53 children before surgery were then tested for bacterial adherence. Retrospectively, the infection rate for infants younger than 6 months old was 15.7% (28 of 178 procedures), compared with 5.6% (16 of 288 procedures) for older children (p = 0.0005). Of all infections, 67% were due to coagulase-negative Staphylococcus. Age was the only major factor influencing the infection rate. Three of the 60 children studied prospectively developed postoperative shunt infections. All were younger than 6 months and all had high skin bacterial densities before surgery. Contamination during surgery was generally low, but correlated with the preoperative skin bacterial density. Strains of coagulase-negative Staphylococcus with high bacterial adherence were more commonly found in neonates than in older children. High skin bacterial density in neonates before surgery was a risk factor for infection in this study. These results also suggest that there is selection of more virulent strains of coagulase-negative Staphylococcus on the skin of neonates. Prevention of shunt infections in this high-risk group could be facilitated by the reduction of skin bacterial density before surgery using chlorhexidine shampoos and by the elimination of contamination by skin bacteria during surgery using packs soaked in an antiseptic agent to isolate wound edges and glove-changing before handling the shunt.