Ventriculostomy-associated infection rates and routine EVD replacement: a systematic review and meta-analysis

External ventricular drainage (EVD) is associated with a significant risk of ventriculostomy-associated infection (VAI), which can lead to severe complications. The relationship between catheterization duration, routine catheter exchange, and infection risk remains debated. This meta-analysis aimed to estimate the contemporary pooled VAI rate and evaluate the effect of catheter type and management strategy on infection risk.

PROSPERO-registered (CRD42025632997) systematic review and meta-analysis. MEDLINE, Cochrane, Embase, Scopus, and CINAHL were searched through February 2024. Studies reporting EVD infection counts with catheter-days were included. Random-effects (DerSimonian-Laird) meta-analysis pooled log-transformed infection rates. Subgroup analyses compared impregnated versus plain catheters and pre-/post-2010 era. Two RCTs were qualitatively synthesized. Risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane RoB2.

Nineteen cohort studies and two RCTs were included. Critically, neither RCT demonstrated benefit from routine replacement (Wong 2002: RR = 1.80, 95% CI 0.33-9.81, p = 0.50; Keong 2012: RR = 0.58, 95% CI 0.33-0.99, favouring silver-impregnated catheters over standard catheters rather than supporting exchange). All 19 observational cohort studies confirmed that routine fixed-interval EVD replacement was not practiced at any included institution, precluding direct observational comparison. Eight cohort studies contributed 167 infections across 22,839 catheter-days to quantitative synthesis. The pooled VAI rate was 7.87 per 1,000 catheter-days (95% CI 4.67-13.25; I²=91%, τ²=0.506). The 95% prediction interval was 1.78-34.85/1,000 catheter-days, reflecting wide variation across settings. Antimicrobial-impregnated catheters had a pooled rate of 4.85 versus 17.03/1,000 catheter-days for plain catheters.

Routine fixed-interval EVD replacement is not supported by current evidence, independently confirming IDSA 2017 Recommendation 78. Antimicrobial-impregnated catheters and infection prevention bundles appear more effective at reducing VAI rates than scheduled catheter exchange alone. Further adequately powered RCTs are needed and research should standardize reporting of institutional replacement practices and evaluate broader-spectrum antimicrobial catheter technologies targeting both gram-positive and gram-negative organisms.