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Incidence and patient-related risk factors for external ventricular drain-related cerebrospinal fluid infections
Aron Alakmeh1, Mergime Maralushaj2, Vittorio Stumpo1
1Machine Intelligence in Clinical Neuroscience & Microsurgical Neuroanatomy (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
Introduction:
Despite procedural standardization, external ventricular drain-related infections (EVD-RI) remain frequent, with reported incidences of 5-30%. The underlying risk factors, however, remain insufficiently understood and have been debated for decades.
Research Question:
To address this, patient-related and periprocedural risk factors for EVD-RI in adults undergoing EVD placement were analyzed.
Materials And Methods:
This single-center cohort included adults receiving EVD implantation between 2014 and 2022. Suspected EVD-RI was defined according to Infectious Diseases Society of America (IDSA). Confirmed EVD-RI required a positive CSF culture and/or broad-range eubacterial PCR. The primary outcome was suspected EVD-RI. Patient-related factors were assessed for their role as independent predictors or confounders using a multivariable Cox proportional hazards model with purposeful variable selection.
Results:
A total of 387 patients with 421 EVDs were included. Suspected EVD-RI occurred in 104 (26.9%) patients and confirmed EVD-RI in 63 (16.3%) patients. EVD exchange (HR: 3.13, 95% CI: 2.02-4.85, p < 0.001), aneurysmal subarachnoid hemorrhage (aSAH) (HR: 2.56, 95% CI: 1.40-4.68, p = 0.002), and non-aneurysmal SAH (HR: 2.11, 95% CI: 0.90-4.96, p = 0.09) were associated with a significantly higher risk, whereas postoperative systemic antibiotics given for other suspected infections (HR: 0.33, 95% CI: 0.21-0.51, p < 0.001) and additional implantation of neuromonitoring (HR: 0.54, 95% CI: 0.30-0.97, p = 0.04) were associated with a significantly lower risk for EVD-RI.
Discussion And Conclusion:
EVD-RI risk is driven primarily by periprocedural rather than patient-related factors. Avoiding EVD exchanges, preventing leaks/obstruction, minimizing drainage duration, and early definitive diversion may reduce infections.
Insights
External ventricular drain-related infections (EVD-RI) are common, with risk factors primarily linked to procedures, not patients. Strategies like avoiding EVD exchanges and managing drainage duration can reduce EVD-RI.
Area of Science:
- Neurosurgery
- Infectious Diseases
- Critical Care Medicine
Background:
- External ventricular drain-related infections (EVD-RI) occur frequently (5-30%) despite standardized procedures.
- Underlying risk factors for EVD-RI remain poorly understood and debated.
- Identifying modifiable risk factors is crucial for infection prevention.
Purpose of the Study:
- To analyze patient-related and periprocedural risk factors for EVD-RI in adults.
- To identify independent predictors and confounders of EVD-RI.
- To inform strategies for reducing EVD-RI incidence.
Main Methods:
- Single-center cohort study of adult EVD placements (2014-2022).
- EVD-RI defined by IDSA criteria, confirmed by CSF culture or PCR.
- Multivariable Cox proportional hazards model used to assess risk factors.
Main Results:
- 26.9% of patients experienced suspected EVD-RI; 16.3% had confirmed EVD-RI.
- Higher risk associated with EVD exchange (HR: 3.13), aneurysmal SAH (HR: 2.56).
- Lower risk associated with postoperative antibiotics (HR: 0.33) and neuromonitoring (HR: 0.54).
Conclusions:
- EVD-RI risk is predominantly driven by periprocedural factors.
- Avoiding EVD exchanges and managing drain duration are key preventive measures.
- Minimizing drainage duration and early definitive diversion may reduce infection rates.
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