Objective: To evaluate the frequency of external ventricular drain (EVD) related infections. Material and Methods: This observational study was conducted at the department of Neurosurgery / pathology, Postgraduate medical institute, Lady Reading Hospital Peshawar from July 2014 to December 2014. A total of 18 consecutive patients, who undergone EVD, irrespective of their age and gender were included in the study. Those who had intracranial infection, Cerebrospinal fluid leak (CSF) or revision of EVD (external ventricular drain) were excluded from the study. Results: We had total 18 patients who underwent EVD in the study period. There were 44.4% males and 55.6% females. Their age range was from 1-69 years with the mean age of 40years. Main indication for EVD was intracranial hemorrhage in 55.6% cases. Post EVD infection was observed in 16.6%. Conclusions: We conclude that external ventricular drainage is an effective and quick technique for the management of acutely raised intracranial pressure with dilated ventricular system. The incidence of EVD related infection is significant (16.6%). Early diagnosis is made on the basis of CSF culture, gram staining and routine evaluation for increased white cell count, increased proteins and decrease glucose level. This will help to permit immediate and specific treatment

Azam, Farooq

Khan, Zahid

Rahman, Safia

Sharafat, Seema

Pakistan Journal Of Neurological Surgery

Pak. J. of Neurol. Surg. – Vol. 19, No. 3, Jul. – Sep., 2015         -150-    ORIGINAL ARTICLE   Frequency of External Ventricular Drain Related Infection  SAFIA RAHMAN, SEEMA SHARAFAT, ZAHID KHAN Farooq Azam Departments of Neurosurgery / Pathology, MTI, Lady Reading Hospital, Peshawar  ABSTRACT Objective:  To evaluate the frequency of external ventricular drain (EVD) related infections. Material and Methods:  This observational study was conducted at the department of Neurosurgery / pathology, Postgraduate medical institute, Lady Reading Hospital Peshawar from July 2014 to December 2014. A total of 18 consecutive patients, who undergone EVD, irrespective of their age and gender were included in the study. Those who had intracranial infection, Cerebrospinal fluid leak (CSF) or revision of EVD (external ventricular drain) were excluded from the study. Results:  We had total 18 patients who underwent EVD in the study period. There were 44.4% males and 55.6% females. Their age range was from 1-69 years with the mean age of 40years. Main indication for EVD was intra-cranial hemorrhage in 55.6% cases. Post EVD infection was observed in 16.6%. Conclusions:  We conclude that external ventricular drainage is an effective and quick technique for the mana-gement of acutely raised intracranial pressure with dilated ventricular system. The incidence of EVD related infection is significant (16.6%). Early diagnosis is made on the basis of CSF culture, gram staining and routine evaluation for increased white cell count, increased proteins and decrease glucose level. This will help to permit immediate and specific treatment. Key Words:  EVD, Hydrocephalus, Infection, Ventricular drain, Ventriculostomy.  INTRODUCTION External ventricular drains (EVD) are commonly used in critical care units for the treatment of acute obstruc-tive hydrocephalus, intracranial pressure monitoring and / or the administration of intraventricular medica-tions.1-3 Complications arising from EVDs include hemorrhage, misplacement, dislodgement, blockage, and, most significantly, infection, which may be com-plicated by ventriculitis, meningitis, brain abscess, or subdural empyema2,4. The overall complication rate ranges from 3.4 to 32.2%.2,4,10  External ventricular drainage (EVD) – related in-fection is one of the most severe complications1. Acco-rding to the literature, the incidence rate of EVD – related infections ranges from 5% to 20% and it is mainly due to gram-positive cocci (Staphylococcus epidermidis or Staphylococcus aureus), but gram – negative bacteria such as Pseudomonas aeruginosa or Acinetobacter baumannii have also been found as causal agents.1,2,11 EVD related infection increase not only mortality but also have severe neurological seq-uelae.1  Diagnosis of EVD-related infection (meningitis, ventriculitis) is based on the presence of biochemical and bacteriological analysis of cerebrospinal fluid (CSF).12 Therefore, the study of cerebrospinal fluid (CSF) remains the key to the diagnosis of EVD-related infections.7,13  As there is limited local study on this topic. This study will help us to assess the frequency of EVD-related infection and thus to help in management of such patients.  MATERIAL AND METHODS This was an observational study of patients who were admitted to the Neurosurgical Department MTI, LRH and underwent the initial EVD insertion over a period Safia Rahman, et al -151-         Pak. J. of Neurol. Surg. – Vol. 19, No. 3, Jul. – Sep., 2015 of 6 months (July to December 2014). We included all the patients in our study requiring EVD system due to hydrocephalus secondary to subarachnoid haemorr-hage (SAH), spontaneous or traumatic intraventricular hemorrhage (IVH), tumors associated with hydroce-phalus, and intraparenchymal bleed of both gender irrespective of their age. The material used for the EVD system was standardized for all samples. We Excluded those patients who had CNS or CSF infect-ion before insertion of the drain or had Reinsertion or revision of the EVD system. After getting approval from the hospital ethical committee to conduct the stu-dy and taking informed consent, Cerebrospinal fluid samples were taken from drain daily for 10 days and were examined for cell count, total protein and glucose concentration. And bacteriological CSF cultures were taken on alternate day. We defined EVD-related infec-tion as positive CSF culture and gram stain and pre-sence of other supportive CSF laboratory findings: 1. Pleocytosis with presence of white blood cells of more than 50 / mm3. 2. A decrease in the CSF glucose level (normal level = 60 mg/dl). 3. An increase in the CSF protein level (normal level = 40 mg/dl).  Patients were not classified as having EVD infe-ctions if only an isolated CSF culture was positive but other parameters were within normal values. All infor-mation was entered into a proforma especially desi-gned for this purpose. The data was analyzed by statis-tical program SPSS version 11.  RESULTS We had total of 18 patients during the study period. Their age ranged from 1 – 69 years with the mean age of 40years. The gender distribution of our patients is given in table 1.  Table 1:  Gender Distribution.  Gender No. of Patients Percentage Ratio Male 08 44.4%   01 Female 10 55.6%   1.25 Total 18 100   Indications for External Ventricular Drains: Main indications are given in table 2. Table 2:  Indications for EVD.  Indications No. of Patients Percentage Spontaneous intracranial bleed 10 55.6% Posterior fossa tumors 04 22.2% Other intracranial tumors  02 11.1% Hydrocephalous 02 11.1% Total 18 100  EVD Related Infection: Three of our cases had EVD related infection. Which make 16.6% of the total 18 cases.  DISCUSSION External ventricular drainage (EVD) is frequently used in neurosurgery to drain cerebrospinal fluid in patients with raised intracranial pressure.14 We performed a retrospective study in order to evaluate the frequency of EVD-related infection. External ventricular drains were placed in 18 patients during our study period of 6 months.  In our study the age of the patients ranged from 1 year to 69 years with the mean age of 40 years. We had more female patients (10/18, 55.6%) than males (8/18, 44.4%). The male to female ratio was 1:1.25. The results are comparable to other studies. Pfisterer and colleagues9 studied 130 patients with external ven-tricular drains. Their age ranged from 6 month to 79 years with the mean age of 46 years. Majority (52.3%) of their patients was female.  The most common indication for putting EVD is raised intracranial pressure after intracranial hemorr-hage.10,15 This was also reflected in our study. We had 55.6% (10/18) patients with spontaneous intracranial hemmohage. In another study it is about 53.8%.9 The rest had other causes for hydrocephalous.  Because external ventricular drains (EVDs) pro-vide access to cerebrospinal fluid (CSF), there is pote-ntial for EVD associated acute bacterial infection 16. In our study, 16.6% (3 cases) patients developed infect-ion. The results wary in different studies. Omar and colleagues 17 studied 87 patients.  In their study the frequency of EVD – related infection was as high as 32.2% (95% CI 23.3% to 42.57%). The cumulative in-cidence of EVD – related infection in Hegel and colle-agues14 study was 8.3% like results were published in other studies.2 Frequency of External Ventricular Drain Related Infection Pak. J. of Neurol. Surg. – Vol. 19, No. 3, Jul. – Sep., 2015         -152-  The device-associated infection rate observed in our study is higher than the rate reported by Schei-thauer, et al,18 (6.3 per 1000 device days) and Hagel, et al, (8.3%). Berger, et al19 shared their long term experience regarding external ventricular drain in pre-term infants. They had 37 such patients and infection rate was 5.4%.  The exact reason for higher infection rate in our study is not clear. However, hemorrhagic cause of hydrocephalous (subarachnoid / intraventricular hem-orrhage), Cerebro-Spinal Fluid leak, and placement of EVD for long duration, systemic or bur–hole site infe-ctions, short subcutaneous tunneling and frequent irri-gation and manipulation of catheter increases inci-dence of infection. Not following aseptic techniques without antibiotic coverage infection chances incre-ases.2  The culture sensitivity report was positive in 72.2% (13 cases) of our patients. In 55.5% (10 cases) the pathogens identified were staphylococci, and in the rest were streptococci, Enterococci etc. in one study the pathogens most commonly identified were co-agulase – negative Staphylococcus (62%) followed by Enterococcus spp. (19%). Gram – negative bacilli were responsible for 50% of the infections, followed by gram – positive cocci (29%) and others (21%).5  Postoperative colonization can either arise from endogenous organisms present on the skin, which spr-ead along the intracutaneous tract or by exogenous organisms introduced into the EVD system during manipulation at the EVD system by healthcare wor-kers. There are data suggesting that increasing the dis-tance from the EVD exit site to the burr hole reduces bacterial colonization and infection of the catheter.20-22 Endogenous infections might be prevented by using antimicrobial coated or silver coated EVD catheters which may decrease bacterial colonization and thus prevent infection as published by Wang, et al,21 and Koeng, et al,23 studies.  CONCLUSION We conclude that external ventricular drainage is an effective and quick technique for the management of acutely raised intracranial pressure with dilated ventri-cular system. The incidence of EVD related infection is significant (16.6%). Early diagnosis is made on the basis of CSF culture, gram staining and routine evalu-ation for increased white cell count, increased proteins and decrease glucose level. This will help to permit immediate and specific treatment. Address for Correspondence: Dr. Zahid Khan Department of Neurosurgery, Lady Reading Hospital Peshawar – Pakistan Cell: 03359345434 E-mail: seemasharafat@yahoo.com  REFERENCES 1. Gordon M, Ramirez P, Soriano A, Palomo M, Lopez-Ferraz C and Villarreal E, et al. Diagnosing external ventricular drain – related ventriculitis by means of loc-al inflammatory response: soluble triggering receptor expressed on myeloid cells-1. Crit Care, 2014; 18 (5): 567. 2. Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES., Jr Ventriculostomy-related infections: a critical review of the literature. Neurosurgery, 2002; 51: 170–181. 3. Beer R, Lackner P, Pfausler B, Schmutzhard E. 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AUTHORS DATA  Name Post Institution E-mail Dr. Safia Rahman  Departments of Neurosurgery / Pathology, MTI, Lady Reading Hospital, Peshawar  Dr. Seema Sharafat   Dr. Zahid Khan  Department of Neurosurgery, PGMI / Lady Reading Hospital, Peshawar – Pakistan seemasharafat@yahoo.com Dr. Farooq azam      

Frequency of External Ventricular Drain Related Infection

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Frequency of External Ventricular Drain Related Infection

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