Ultra-Late shunt infection in the paediatric population

Referral to neurosurgical services for suspected shunt infection commonly occurs in shunted children who present with fever and sepsis of unknown origin. While early shunt infections are common, ultra-late shunt infections (Beyond 1 year) are exceedingly rare. This study aims to investigate the incidence and causes of ultra-late shunt infection within the paediatric neurosurgical population.

We conducted a retrospective study of all shunt procedures performed between the years 2010 and 2025. Delayed shunt infections were defined as infections occurring 1 year or later after shunt insertion that required externalization or removal of the shunt. Our inclusion criteria encompassed all paediatric neurosurgical patients under the age of 18 who presented to a single paediatric neurosurgical centre with pyrexia, investigated for the source of sepsis, and were confirmed to have a shunt infection. Shunt infection was confirmed clinically with a cerebrospinal fluid (CSF) sample indicating active infection, (raised CSF White cell count, with or without a confirmed microorganism), necessitating the removal or externalization of the shunt. Patients who underwent shunt externalization prophylactically for major abdominal surgery, but did not have a shunt infection, were excluded from this study. All patients had internalization of shunt following completion of treatment with appropriate antibiotics and confirmation of sterile CSF. Information including age, sex, aetiology of hydrocephalus, interval between shunt insertion and shunt infection, risk factors of infection and micro-organism isolated were also analysed to elucidate cause and pattern of infection.

Overall, 1670 shunt procedures were undertaken between 2010 and 2025. 15 cases of ultra-late shunt infection occurred during the same period. The ultra-late shunt infection cohort had a mean age of 5 years (Range 1-11 years) with an M: F ratio of 1.5:1 (9:6). Hydrocephalus secondary to intraventricular haemorrhage of prematurity was the most common cause of hydrocephalus. The mean interval delay between shunt insertion and infection was 4.74 years. The most common cause of ultra-late shunt infection was abdominal sepsis or pathology. Enterococcus species was found to be the causative microorganism in 33.3 % of cases. All cases required externalisation or removal of the shunt, followed by intravenous antibiotic therapy, followed by internalisation.

Ultra-late shunt infection occurs rarely at a rate of 0.9 % over 15 years (annual rate of 0.06 %) in this cohort of paediatric neurosurgical patients. Abdominal source is the most common cause of ultra-late shunt infection in children.