Effect of Bundled Care on External Ventricular Drain Infections: A Systematic Review and Meta-analysis

External ventricular drains (EVDs) are critical for managing acute intracranial conditions but are associated with infections. We conducted a systematic review and meta-analysis to evaluate whether the implementation of infection prevention bundles reduces the risk of EVD-associated infections, which was registered with PROSPERO on July 25, 2024 ( https://www.crd.york.ac.uk/prospero/ ): CRD42024573168. PubMed, EMBASE, and Scopus databases were systematically searched for studies reporting EVD infection rates with and without bundle implementation. Two reviewers independently assessed bundle element presence and extracted infection outcomes. The meta-analysis was performed using a random-effects model with Hartung-Knapp adjustment, and heterogeneity was assessed using the I² statistic. An exploratory subgroup analysis compared bundle element implementation between studies achieving <5% infection rates and those with ≥5%. Twenty-two studies were analyzed, including 6330 patients (3895 in the bundle group and 2435 in the nonbundle group). Hand hygiene (100%) and administration of preinsertion antibiotics (91%) were the most frequently implemented bundle elements, whereas structured weaning protocols were infrequently reported (9%). Bundle implementation was associated with a significant reduction in EVD infection risk (pooled Risk Ratio [RR]: 0.46, 95% CI: 0.33-0.65, P <0.001). Moderate heterogeneity was observed across studies (I²=50.9%). The use of antimicrobial-impregnated catheters, tunneled catheter placement, and structured education programs were more frequently present among studies achieving infection rates <5%. Implementing an infection prevention bundle is associated with a significant reduction in EVD infections. Adoption of core practices, supplemented by technology enhancements and education programs, may further optimize infection prevention strategies.