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EVD-associated infections (EVDAI) - Clinical impact and strategies to reduce the incidence

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Michel Roethlisberger
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Objective: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus during the first 2 weeks after aneurysmal subarachnoid hemorrhage (aSAH) shortens the duration of external ventricular drainage (EVD) and reduces EVD-associated infections (EVDAI). The objective of this study was to detect any association with symptomatic delayed cerebral vasospasm (DCVS), or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: We used a single-center dataset of aSAH patients who had received a permanent CSF diversion. We compared an 'early group' in which the procedure was performed up to 14 days after the ictus, to a 'late group' in which it was performed from the 15th day onward. Results: Among 274 consecutive aSAH patients, 39 (14%) had a permanent CSF diversion procedure following a silver-coated EVD. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39; 51%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with less colonized catheter, a shorter duration of extracorporeal CSF diversion (OR 0.73, 95%CI 0.58-0.92 per EVD day), and a lower rate of EVDAI (OR 0.08, 95%CI 0.01-0.80). The occurrence of CSF diversion device obstruction, the rate of symptomatic DCVS or detected DCI on computed tomography and the likelihood of a poor outcome at discharge did not differ between the two groups. Discussion: Early permanent CSF diversion lowers the occurrence of catheter colonization and infectious complication without affecting DCVS-related morbidity in good-grade aSAH patients. These findings need confirmation in larger prospective multicenter cohorts.
Michel Roethlisberger
added a research item
Background: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) might shorten the duration of external ventricular drainage (EVD) and thereby reduce infectious complications. The potential effect on the rate of delayed cerebral vasospasm (DCVS) and associated morbidity has not been studied to date. The objective of this study was to detect any association with EVD-associated infections (EVDAI), symptomatic DCVS, or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: A single-center dataset of aSAH patients who received a permanent CSF diversion procedure between 2009 and 2018 was used for the evaluation. The subjects were divided into an “early group” if such a procedure was performed up to 14 days after the ictus, and a “late group” if it was performed from the 15 th day onward. The statistical analysis employed univariable and multivariable logistic regression models. Results: Among 274 consecutive aSAH patients, 39 (14.2 %) had a permanent CSF diversion procedure. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39, 51.2%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with a shorter duration of EVD (OR 0.73, 95%CI 0.58-0.92 per day). Higher catheter colonization to EVDAI ratio (1/7 out of 20 vs. 7/7 out of 19) and a markedly lower frequency of EVDAI (OR 0.08, 95 %CI 0.01-0.80) were detected. The prevalence (5 vs. 37) and the cumulative incidence (3 vs. 18) of EVDAI were remarkably lower in patients receiving early permanent CSF diversion. The occurrence of CSF-diversion device obstruction, the rate of symptomatic DCVS (OR 0.61, 95 %CI 0.16-2.27) or detected DCI on computed tomography (OR 0.35, 95 %CI 0.08-1.47), and the likelihood of a poor outcome at discharge did not differ between the two groups (OR 0.88, 95%CI 0.24-3.22). Conclusions: Early permanent CSF diversion in good grade aSAH patients is associated with a shorter duration of EVD, lower catheter colonization rates, and fewer infectious complications. The timing of permanent CSF diversion had no detectable effect on DCVS-related morbidity. These findings need to be confirmed in larger cohorts.
Michel Roethlisberger
added a research item
Background: Observational studies have shown that dressings containing chlorhexidine gluconate (CHX) lower the incidence external ventricular drain (EVD) associated infections (EVDAI). This prospective, randomized controlled trial (RCT) studies the efficacy of CHX-containing dressings in reducing bacterial colonization, which represents an important risk factor for infectious complications. Methods: In this single-site, prospective, double-blinded RCT, patients aged ≥18 undergoing emergency EVD placement were randomly given either a CHX- or an otherwise identical control dressing at the skin exit wound of the EVD. The primary endpoint was bacterial regrowth in cultured skin swabs of the EVD exit wound before dressing application and after 5 days. Catheters were processed by sonication. The secondary endpoints were clinically diagnosed EVDAI and surgical treatment of hydrocephalus. Results: From October 2013 to January 2016, 57 patients were randomized to receive either a CHX- or a control dressing (29 and 28 patients, respectively). Cutaneous bacterial regrowth at the EVD exit wound was significantly reduced over time (OR 0.18, 95% CI 0.08, 0.42, p≤.0001). The incidence of colonized catheters was lower in the CHX- (5/28 [18%]) compared to the control group (10/27 [33%]) with less microbial colonization on the subcutaneous portion (0.22 [0.04, 1.07] p=.059). The infection rate was 4/28 (14%) in the CHX- compared to 7/27 (26%) in the control group with a substantially lower hydrocephalus treatment rate (7/28 [25%] and 14/27 [52%]) respectively. Conclusion: Our data support the use of CHX dressings to reduce EVD exit site contamination, potentially EVDAI and permanent cerebrospinal fluid diversion procedures for hydrocephalus.