Comparative effectiveness of antibiotic-impregnated shunt catheters in the treatment of adult and pediatric hydrocephalus: analysis of 12,589 consecutive cases from 287 US hospital systems

OBJECT The real-world effectiveness of antibiotic-impregnated shunt catheters to reduce the incidence of shunt infections is still debated. The literature to date consists mostly of small, single-institution studies. The aim of this study was to assess the incidence of infection for antibiotic-impregnated catheters (AICs) versus standard shunt catheters in a large nationwide administrative database. METHODS The authors retrospectively reviewed hospital discharge and billing records from the Premier Perspective Database from April 2003 to July 2009 to identify all adult and pediatric patients undergoing de novo ventricular shunt placement. The primary end point was the incidence of shunt infection within 1 year of implantation. Multivariate logistical regression was performed to determine factors associated with increased incidence of infection. RESULTS A total of 10,819 adult (AIC, 963; standard catheter, 9856) and 1770 pediatric (AIC, 229; standard catheter, 1541) patients underwent ventricular shunt placement in 287 US hospitals. Overall, the incidence of infection was 3.5% in adults (n = 380) and 6.6% in pediatric patients (n = 116). AICs were associated with significant reduction in infection for both adult (2.2% vs 3.6%, p = 0.02) and pediatric (2.6% vs 7.1%, p < 0.01) patients. AIC use was associated with reduced infection regardless of hospital size, annual shunt volume, hospital location, or patient risk factors and remained associated with a reduced infection in multivariate analysis for both adult (p = 0.02) and pediatric (p = 0.02) patients. CONCLUSIONS The use of antibiotic-impregnated shunt catheters was associated with a reduction in shunt infections for both adult and pediatric patients. This provides further support that AICs may represent a reliable means of reducing shunt infections for both adult and pediatric patients.

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A Multicenter Multinational Registry for Assessing Ventriculoperitoneal Shunt Infections for Hydrocephalus

Neurosurgery ◽

10.1227/neu.0b013e3181f07e76 ◽

2010 ◽

Vol 67 (5) ◽

pp. 1303-1310 ◽

Cited By ~ 24

Author(s):

Paul Steinbok ◽

Ruth Milner ◽

Deepak Agrawal ◽

Elana Farace ◽

Gilberto K K Leung ◽

...

Keyword(s):

Infection Rate ◽

Ventriculoperitoneal Shunt ◽

De Novo ◽

Controlled Trial ◽

Shunt Infection ◽

Infection Rates ◽

Open Label ◽

Shunt Infection Rate ◽

Catheter Implantation ◽

Shunt Infections

Abstract BACKGROUND: Reported infection rates after ventriculoperitoneal shunt surgery vary from 1 to 25%. Antibiotic-impregnated (AI) catheters may reduce shunt infection rates, but this is uncertain. OBJECTIVE: To establish a prospective shunt registry to evaluate short-term (3-month) infection rates associated with ventriculoperitoneal shunts and standard or AI catheters during surgical treatment of hydrocephalus. METHODS: A prospective, multicenter, noncontrolled, open-label registry investigated patients with de novo catheter implantation or catheter replacement of an existing ventriculoperitoneal shunt. The primary outcome was shunt infection. RESULTS: A total of 440 patients were entered into the registry at 10 sites: 3 in North America, 2 in Singapore, 4 in China and 1 in India. Seven patients were excluded. Of the 433 remaining patients, 314 had new shunts and 119 were revisions. Shunt infections occurred in 14 of 433 patients (3.2%) overall and in 2 of 37 infants (5.2%) younger than 1 year. AI catheters were used in 46 of 433 patients at 7 centers. The shunt infection rate was 0 of 46 for shunts with AI catheters and 14 of 387 (3.6%) without AI catheters. Infection rates were similar with AI catheters, adjusting for age and catheter type. CONCLUSION: The overall shunt infection rate was lower than in previous multicentered studies. The low infection rate and low rate of AI catheter use precludes any meaningful statement regarding the value of AI catheters in reducing the infection rate. Consideration should be given to performing a well designed, adequately powered, prospective randomized controlled trial to determine whether AI catheters reduce shunt infection rates.

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Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.3.peds08215 ◽

2009 ◽

Vol 4 (2) ◽

pp. 156-165 ◽

Cited By ~ 152

Author(s):

Tamara D. Simon ◽

Matthew Hall ◽

Jay Riva-Cambrin ◽

J. Elaine Albert ◽

Howard E. Jeffries ◽

...

Keyword(s):

The United States ◽

Shunt Infection ◽

Csf Shunt ◽

Infection Rates ◽

Study Objective ◽

Shunt Placement ◽

Pediatric Hospitals ◽

Csf Shunt Infection ◽

Shunt Infections

Object Reported rates of CSF shunt infection vary widely across studies. The study objective was to determine the CSF shunt infection rates after initial shunt placement at multiple US pediatric hospitals. The authors hypothesized that infection rates between hospitals would vary widely even after adjustment for patient, hospital, and surgeon factors. Methods This retrospective cohort study included children 0–18 years of age with uncomplicated initial CSF shunt placement performed between January 1, 2001, and December 31, 2005, and recorded in the Pediatric Health Information System (PHIS) longitudinal administrative database from 41 children's hospitals. For each child with 24 months of follow-up, subsequent CSF shunt infections and procedures were determined. Results The PHIS database included 7071 children with uncomplicated initial CSF shunt placement during this time period. During the 24 months of follow-up, these patients had a total of 825 shunt infections and 4434 subsequent shunt procedures. Overall unadjusted 24-month CSF shunt infection rates were 11.7% per patient and 7.2% per procedure. Unadjusted 24-month cumulative incidence rates for each hospital ranged from 4.1 to 20.5% per patient and 2.5–12.3% per procedure. Factors significantly associated with infection (p < 0.05) included young age, female sex, African-American race, public insurance, etiology of intraventricular hemorrhage, respiratory complex chronic condition, subsequent revision procedures, hospital volume, and surgeon case volume. Malignant lesions and trauma as etiologies were protective. Infection rates for each hospital adjusted for these factors decreased to 8.8–12.8% per patient and 1.4–5.3% per procedure. Conclusions Infections developed in > 11% of children who underwent uncomplicated initial CSF shunt placements within 24 months. Patient, hospital, and surgeon factors contributed somewhat to the wide variation in CSF shunt infection rates across hospitals. Additional factors may contribute to variation in CSF shunt infection rates between centers, but further study is needed. Benchmarking and future prospective multicenter studies of CSF shunt infection will need to incorporate these and other patient, hospital, and surgeon factors.

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The association between dental health and procedures and developing shunt infections in pediatric patients

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.8.peds1444 ◽

2014 ◽

Vol 14 (5) ◽

pp. 508-513 ◽

Cited By ~ 3

Author(s):

Alan A. Moazzam ◽

Ernest Nehrer ◽

Stephanie L. Da Silva ◽

José C. Polido ◽

Anush Arakelyan ◽

...

Keyword(s):

Bacterial Infections ◽

Pediatric Patients ◽

Pediatric Population ◽

Dental Health ◽

Shunt Infection ◽

Dental Procedure ◽

Gingival Health ◽

Dental Procedures ◽

Dental Records ◽

Shunt Infections

Object Cerebrospinal fluid–diverting shunts are often complicated by bacterial infections. Dental procedures are known to cause transient bacteremia that could potentially spread hematogenously to these implanted devices. No literature currently exists to inform practitioners as to the need for prophylactic antibiotics for patients who possess these implants. The authors performed a retrospective study to assess whether dental procedures and poor oral health were associated with a higher likelihood of developing CSF-diverting shunt infections. Methods Neurosurgical and pediatric dental records from January 2007 to December 2012 were reviewed for shunt surgeries and dental encounters. Indications for shunt surgery and infection rates were recorded. Dental records were reviewed for several markers of overall dental health, such as a DMFT (decayed, missing, and filled teeth) score and a gingival health/oral hygiene score. The association between these scores and the incidence of shunt infections were studied. Moreover, the relationship between the incidence of shunt infections and the timing and invasiveness of preceding dental encounters were analyzed. Results A total of 100 pediatric patients were included in our study, for a total of 204 shunt surgeries. Twenty-one shunt infections were noted during the 6-year study period. Five of these shunts infections occurred within 3 months of a dental procedure. The odds ratio (OR) of developing a shunt infection within 3 months of a dental procedure was 0.98 (95% confidence interval [CI] 0.27–3.01), and was not statistically significant. The OR of developing a shunt infection after a high-risk dental procedure compared with a low-risk dental procedure was 1.32 (95% CI 0.02–16.29), and was not statistically significant. There was no significant association between measures of dental health, such as DMFT and gingival health score, and the likelihood of developing a shunt infection. The ORs for these 2 scores were 0.51 (95% CI 0.04–4.96) and 1.58 (95% CI 0.03–20.06), respectively. The study was limited by sample size. Conclusions Dental health status and the number and type of dental procedures performed do not appear to confer a higher risk of developing a CSF-diverting shunt infection in this pediatric population.

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Factors contributing to the medical costs of cerebrospinal fluid shunt infection treatment in pediatric patients with standard shunt components compared with those in patients with antibiotic-impregnated components

Neurosurgical FOCUS ◽

10.3171/foc.2007.22.4.11 ◽

2007 ◽

Vol 22 (4) ◽

pp. 1-4 ◽

Cited By ~ 30

Author(s):

Daniel M. Sciubba ◽

Li-Mei Lin ◽

Graeme F. Woodworth ◽

Matthew J. McGirt ◽

Benjamin Carson ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pediatric Patients ◽

Pediatric Population ◽

Medical Costs ◽

Shunt Infection ◽

Csf Shunt ◽

Shunt Insertion ◽

Average Hospital ◽

Infection Treatment ◽

Shunt Infections

Object Antibiotic-impregnated shunt (AIS) systems may decrease the incidence of cerebrospinal fluid (CSF) shunt infections. However, there is a reluctance to use AIS components because of their increased cost. In the present study the authors evaluated factors contributing to the medical costs associated with the treatment of CSF shunt infections in a hydrocephalic pediatric population, those implanted with AIS systems compared with those implanted with standard shunt systems. Methods The authors retrospectively reviewed data obtained in all pediatric patients who had undergone CSF shunt insertion at their institution over a 3-year period. All patients were followed up for 12 months after surgery. The independent association between AIS catheter use and subsequent shunt infection was assessed by performing a multivariate proportional hazards regression analysis. Factors contributing to the medical costs associated with shunt infection were evaluated. Results Two hundred eleven pediatric patients underwent 353 shunting procedures. Two hundred eight shunts (59%) were placed with nonimpregnated catheters and 145 shunts (41%) were placed with AIS catheters. Twenty-five patients (12%) with non-AIS catheters experienced shunt infection, whereas only two patients (1.4%) with AIS catheters had a shunt infection within the 6-month follow-up period (p < 0.01). Among infected patients, infected patients with standard shunt components had a longer average hospital stay, more inpatient complications related to infection treatment, and more multiple organism infections and multiple antibiotic regimens, compared with those with AIS components. Conclusions Although individual AIS components are more expensive than standard ones, factors contributing to medical costs are fewer in pediatric patients with infected shunts when the components are antibiotic-impregnated rather than standard.

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Hospital Costs Associated With Shunt Infections in Patients Receiving Antibiotic-Impregnated Shunt Catheters Versus Standard Shunt Catheters

Neurosurgery ◽

10.1227/01.neu.0000363405.12584.4d ◽

2010 ◽

Vol 66 (2) ◽

pp. 284-289 ◽

Cited By ~ 65

Author(s):

Frank J. Attenello ◽

Giannina L. Garces-Ambrossi ◽

Hasan A. Zaidi ◽

Daniel M. Sciubba ◽

George I. Jallo

Keyword(s):

Hospital Cost ◽

Pediatric Patients ◽

Hospital Costs ◽

The United States ◽

Shunt Infection ◽

Csf Shunt ◽

Total Hospital Cost ◽

Total Hospital ◽

Csf Shunts ◽

Shunt Infections

Abstract BACKGROUND The average hospital cost for shunt infection treatment is $50 000, making it the most financially costly implant-related infection in the United States. We set out to determine whether introduction of antibiotic-impregnated shunts (AISs) in our practice has decreased the incidence of shunt infection or decreased infection-related hospital costs at our institution. METHODS Clinical and hospital billing records of pediatric patients undergoing cerebrospinal fluid (CSF) shunt insertion at a single institution from April 2001 to December 2006 were retrospectively reviewed. Eighteen months before October 2002, all CSF shunts included standard, non-AIS catheters. During the 4 years after October 2002, all CSF shunts included AIS catheters. Patients were followed at least 18 months after surgery. RESULTS A total of 406 pediatric patients underwent 608 shunt placement procedures (400 AISs, 208 non-AISs). Of patients with non-AIS catheters, 25 (12%) experienced shunt infection, whereas only 13 patients (3.2%) with AIS catheters experienced shunt infection during follow-up (P < .001). The total hospital cost to treat 25 non-AIS shunt infections over the first 18 months was $1,234,928. The total hospital cost to treat 13 AIS shunt infections over the past 4 years was $606,328. The mean hospital cost per shunt infection was similar for infected AIS and non-AIS catheters ($46 640 vs. $49 397). However, the infection-related hospital cost per 100 patients shunted was markedly lower in the AIS cohort than in the non-AIS cohort ($151 582 vs. $593 715). DISCUSSION The introduction of AIS catheters in our institutional practice reduced the incidence of shunt infection and resulted in significant hospital cost savings. AIS systems are efficient and cost-effective instruments to prevent perioperative colonization of CSF shunt components.

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Intraoperative Injection of Intraventricular Antibiotics is Associated With a Decreased Incidence of Infection and Revision Surgery in Pediatric Hydrocephalus Patients Undergoing Shunt Placement

Neurosurgery ◽

10.1093/neuros/nyz310_200 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Nikita Lakomkin ◽

Constantinos G Hadjipanayis

Keyword(s):

Pediatric Patients ◽

Patient Characteristics ◽

Definitive Treatment ◽

Shunt Revision ◽

Csf Leak ◽

Shunt Placement ◽

Pediatric Hydrocephalus ◽

Additional Surgery ◽

Initial Procedure ◽

Multivariable Regression

Abstract INTRODUCTION Infection is the most common cause of morbidity and additional intervention following the placement of a ventriculoperitoneal shunt, even with the use of antibiotic-impregnated catheters. At present, no studies have demonstrated the utility of intraoperative, intraventricular antibiotic injection in reducing the rates of infection and shunt revision. METHODS A prospective, multicenter, shunt-specific neurosurgical registry was used to identify all pediatric patients undergoing first-time placement of a shunt for the definitive treatment of hydrocephalus. All patients who received intraventricular antibiotics (eg, vancomycin or gentamicin) via the shunt catheter during surgery were identified. A variety of variables, including prior temporizing measures (ventriculostomy, subgaleal shunt, reservoir, etc), use of surgical adjuncts (antibiotic-impregnated catheter, stereotactic guidance, choroid plexus coagulation), and reasons for unplanned interventions (infection, CSF leak, catheter obstruction) were collected for each patient. Bivariate statistics and multivariable regression modeling were used to explore the relationship between prophylactic, intraventricular antibiotic placement and subsequent outcomes. RESULTS A total of 2193 pediatric patients undergoing shunt placement for hydrocephalus were identified. Of these, 552 (25.2%) underwent intraoperative injection of antibiotics into the ventricular space. Postoperatively, 104 (4.7%) patients had unplanned removal, replacement, or revision of their shunt at a mean of 14.2 +/− 9 d following the initial procedure. A total of 29 (27.9%) of these interventions were secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, use of image guidance, and placement of an antibiotic-impregnated shunt, intraoperative injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (OR = 0.217, 95% CI: 0.051–0.916, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.36%) went on to develop an infection. CONCLUSION Pediatric patients who received prophylactic, intraoperative injection of intraventricular antibiotics experienced a significantly decreased incidence of additional surgery secondary to infection, even when controlling for the use of antibiotic-impregnated catheters.

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Intraventricular Vancomycin In Pediatric Patients With Cerebrospinal Fluid Shunt Infections

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-9.1.36 ◽

2004 ◽

Vol 9 (1) ◽

pp. 36-42 ◽

Cited By ~ 1

Author(s):

Majed Al-Jeraisy ◽

Stephanie J. Phelps ◽

Michael L. Christensen ◽

Stephanie Einhaus

Keyword(s):

Cerebrospinal Fluid ◽

Pediatric Patients ◽

Shunt Infection ◽

Csf Shunt ◽

Older Children ◽

Vancomycin Concentration ◽

Patients Âgés ◽

Vancomycin Trough ◽

Serum Vancomycin ◽

Shunt Infections

OBJECTIVES To determine: 1) the range and magnitude of vancomycin trough cerebrospinal fluid (CSF) concentrations following intraventricular (IVT) vancomycin; 2) any correlation between patient demographic and CSF vancomycin concentrations; and 3) eradication and complications rates following IVT vancomycin. METHODS Medical records of pediatric patients with shunt infection who received IVT vancomycin during a 12 month period were reviewed. Demographic, microbiological data, IVT/intravenous (IV) vancomycin dosing, concomitant antibiotics, CSF and serum vancomycin concentrations, and CSF drainage output were recorded. RESULTS Seventeen patients ages 4 months to 17 years were hospitalized for shunt infection. Staphylococcus epidermidis (n=12) was the predominant organism. Sixteen patients received 10 mg, and one patient received 5 mg of IVT vancomycin for 3–23 days. All but one received concurrent IV vancomycin. The mean maximum trough CSF vancomycin concentration noted for 16 patients who recieved 10 mg of IVT vancomycin was 18.4±21.8 μg/mL (range: between 0.4 to 187.3 μg/mL). All four adolescents ≥25 kg had CSF vancomycin concentrations ≤5 μg/mL, three of four infants/children between 10.1 and 24.9 kg had trough CSF vancomycin concentrations between 10–20 μg/mL, and five of nine infants <10 kg had CSF concentrations >20 μg/mL. All organisms were successfully eradicated. One patient developed chronic eosinophilia presumed related to elevated CSF vancomycin concentrations (187 μg/mL). CONCLUSIONS –The combination of IVT and IV vancomycin effectively eradicated CSF shunt infections. CSF vancomycin concentrations are highly variable and poorly correlated with age and CSF output. Following a 10 mg IVT vancomycin dose, CSF concentrations appear to be lower in older children and elevated in infants/young children. One infant experienced a complication related to an elevated CSF vancomycin concentration; hence, therapy must be individualized, using CSF trough vancomycin concentrations.

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A simple method to reduce infection of ventriculoperitoneal shunts

Journal of Neurosurgery Pediatrics ◽

10.3171/2010.2.peds09151 ◽

2010 ◽

Vol 5 (6) ◽

pp. 569-572 ◽

Cited By ~ 40

Author(s):

Atiq-ur Rehman ◽

Tausif-ur Rehman ◽

Hassaan H. Bashir ◽

Vikas Gupta

Keyword(s):

Shunt Infection ◽

Control Group ◽

Simple Method ◽

Vp Shunt ◽

Shunt Placement ◽

Shunt Catheter ◽

Skin Flora ◽

Group A ◽

Group B ◽

Shunt Infections

Object Postoperative shunt infection is the most common and feared complication of ventriculoperitoneal (VP) shunt placement for treatment of hydrocephalus. The rate of shunt infection is highest in the 1st postoperative month. The most common organisms responsible for shunt infection include coagulase-negative Staphylococcus and Staphylococcus aureus. This suggests a transfer of patient's skin flora via the surgeons' glove as a possible means of infection. The authors conducted a study to determine if the rate of postoperative shunt infections could be reduced simply by changing gloves before handling the shunt catheter. Methods A total of 111 neonates born with congenital hydrocephalus requiring a VP shunt were enrolled retrospectively and divided into 2 groups: a control group of 54 neonates treated with standard protocol VP shunt placement (Group A) and a treatment group of 57 neonates in whom, after initially double gloving, the outer pair of gloves was removed before handling the shunt catheter (Group B). Shunt infection rates were compared up to 6 months postoperatively. Results There was a statistically significant reduction of infection rate from 16.33% in Group A (control) to 3.77% in Group B (p = 0.0458). Conclusions The study shows that a changing of gloves before handling the shunt catheter may be a simple and cost-effective way to reduce the burden of postoperative shunt infections.

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Cerebrospinal fluid eosinophilia in children with ventricular shunts

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/1/4/288 ◽

2008 ◽

Vol 1 (4) ◽

pp. 288-295 ◽

Cited By ~ 11

Author(s):

Daniel H. Fulkerson ◽

Joel C. Boaz

Keyword(s):

Cerebrospinal Fluid ◽

Shunt Infection ◽

Common Finding ◽

Csf Shunts ◽

Shunt Insertion ◽

Posthemorrhagic Hydrocephalus ◽

Shunt Placement ◽

Increased Risk ◽

Using Data ◽

Shunt Infections

Object Eosinophils have been reported in children with cerebrospinal fluid (CSF) shunts. The goal of this study was to describe the risk factors, relationship to infection, and clinical significance of CSF eosinophilia in a large group of shunt-treated patients. Methods The authors performed a retrospective review of data obtained in all patients who underwent ventricular shunt placement or revision at the James Whitcomb Riley Hospital for Children between 2000 and 2004. Results Eosinophils were identified during a follow-up shunt evaluation in 93 (31%) of 300 patients after initial shunt placement. Eosinophilia was statistically related to CSF extravasation (p < 0.0001), shunt infection (p = 0.031), blood in CSF (p < 0.0001), younger age at shunt insertion (p = 0.030), and the diagnosis of posthemorrhagic hydrocephalus (p < 0.0001). Patients with CSF eosinophilia had a higher risk of subsequent shunt failure (p < 0.0001). Analysis was performed using data obtained in a cohort of patients with a total of 130 shunt infections. Cerebrospinal fluid eosinophils were identified in 118 infections (90.8%). The leukocytic and eosinophilic reactions were dependent on the infecting organism. Propionibacterium acnes had a statistically lower CSF leukocyte count but higher differential percentage of eosinophils than the other common pathogens. Conclusions Cerebrospinal fluid eosinophilia is a relatively common finding in children with shunts. Patients with CSF eosinophilia had an increased risk of shunt malfunction in the present series. Eosinophilia is associated with infection, CSF extravasation, and blood in the CSF. Patients with P. acnes–induced shunt infections have higher eosinophil percentages than are found in infections associated with other common organisms. Therefore, in patients with eosinophilia, extended anaerobic culture studies should be performed with particular attention paid to searching for this pathogen.

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The Effectiveness of Antibiotic-Coated Ventriculoperitoneal Shunts for Prevention of Shunt Infections in Patients with Myelomeningocele

Pediatric Neurosurgery ◽

10.1159/000516379 ◽

2021 ◽

pp. 1-4

Author(s):

Bilal Ertuğrul ◽

Metin Kaplan ◽

Ömer Batu Hergünsel ◽

Bekir Akgün ◽

Sait Öztürk ◽

...

Keyword(s):

Protective Effect ◽

Statistical Difference ◽

Shunt Infection ◽

Infection Rates ◽

Ventriculoperitoneal Shunts ◽

Significant Statistical Difference ◽

Shunt Infections

Purpose: Hydrocephalus is a common comorbidity among the newborns, with myelomeningocele (MMC) and ventriculoperitoneal (VP) shunts being frequently used for the treatment of such patients. In this study, we aimed to compare the effectiveness of antibiotic-free and antibiotic-coated shunts to reduce the rate of shunt infection in patients with hydrocephalus and accompanying MMC. Methods: 116 patients with hydrocephalus and MMC who were treated with VP shunts were included in the study. Shunt infection rates among antibiotic-free and antibiotic-coated shunts were compared. Results: Of the 116 patients included in the study, 39 had antibiotic-coated shunts and 77 had antibiotic-free shunts. Shunt infection developed in 4 of the 39 cases treated with antibiotic-coated shunts and in 5 of the 77 cases treated with shunts without antibiotics. No significant statistical difference was found between antibiotic-coated and antibiotic-free VP shunts in terms of shunt infection (p = 0.450, p > 0.05). Conclusion: In patients with MMC, using VP shunts containing antibiotics was found not to have a protective effect in preventing shunt infection. Whether the sac is intact or ruptured does not affect this result.

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