Evaluation of Risk Factors for Recurrent Ventriculoperitoneal Shunt Infections in Adult

Evaluation of Risk Factors for Recurrent Ventriculoperitoneal Shunt Infections in Adult | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Risk Factors for Recurrent Ventriculoperitoneal Shunt Infections in Adult Neval Elgormus, Huseyin Dogu, Omer Okuyan, Fatma Bozkurt, Abdulhalim Senyigit, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4792129/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : The objective of this paper is to evaluate demographic, clinical, laboratory and microbiological features of ventriculoperitoneal shunt (VPS) infections in this 13 year retrospective study. VPS-related bacterial agents and their antibiotic sensitivity were also investigated in single VPS (SVPS) and recurrent VPS (RVPS) infections. Methods: The study included 110 patients with SVPS infection and 55 patients with RVPS infection. Results: In patients who developed multiple infections, gram-negative organisms were the most predominant (60%, 54/90). Resistance rates were 85.2% for third generation cephalosporins, 83.3% for Piperacillin-Tazobactam, and 10.4% for Carbapenem's. Forty-nine % of patients in the SVPS and 84.4% in the RVPS infection group were treated with combinations of carbapeneme. Central nervous system (CNS) tuberculosis as the etiology of hydrocephalus, short duration of antibiotics used for treatment, high cerebrospinal fluid (CSF) protein and blood C-reactive protein (CRP) levels, and prolonged use of prophylactic antibiotics was found related to increased rate of recurrent infection occurrence. Two-stage shunt change decreased the risk of recurrent infections. Conclusions: VPS infection may be life-threating and its management rucial. Rational and appropriate use of antibiotics and treatment methods according to the algorithms can reduce recurrent infections. Gram-negative predominant bacterial colonization and its carbapenem sensitivity in RVPS infection has to be kept in mind to manage the infection effectively. Ventriculoperitoneal shunt infection resistant gram-negative bacteria carbapenem Introduction Hydrocephalus, enlargement of the intraventricular system and subarachnoid space, is a pathological clinical process that may result as a complication of intracranial haemorrhage, tumour, infection, or brain injury ( 1 ). For management of this complication, ventriculoperitoneal shunt (VPS) is used to decrease the intracranial pressure. However, the risk of postoperative infection is high which may lead to unsuccessful outcome and intracranial infection. The management of VPS infecton is crucial because of its life threatening progress ( 2 ). Risk factors for shunt infection have been previously shunt-associated infection, revision of dysfunctional shunts and postoperative cerebrospinal fluid (CSF) leakage ( 3 – 9 ). There are very few studies on the evaluation of risk factors and treatment approach related to recurrent VPS (RVPS) infection. Non-standard use of antibiotics and inadequate guideline for management of VPS infection can lead to an increase in antibiotic resistance and recurrent infections ( 8 – 11 ). Risk factors in the literature are usually different in pediatric and adult cases. In pediatric cases, gender, age at shunt insertion (young age; <6 months), preterm birth, immune status, etiology of hydrocephalus, type of hydrocephalus, recent shunt revision, previous shunt infection, opening of the skin at the shunt insertion or incision site, CSF leakage from the incision site, prolonged operation time, surgeon experience, lack of prophylactic perioperative antibiotics, and use of neuroendoscope during the operation are the main risk factors ( 2 , 12 – 14 ). Major risk factors in adult cases are infection of the previous shunt, revision of the shunt for dysfunction, multiple revisions, CSF leakage from the post-operative skin incision, advancing age (advanced age), operation time, surgeon's experience, and use of neuroendoscope ( 2 , 15 ). In the present study, we aimed to retrospectively analyze a large series of patients who experienced long term proximal VPS infections, to describe the epidemiological, clinical, laboratory, and microbiological characteristics and treatment outcomes, and to identify the risk factors for recurrent-infection in adults. Materials and Methods This case-control study was conducted at the Istanbul Atlas University, Medicine Hospital, Department of Infectious Diseases and Clinical Microbiology, and University of Health Science, Gazi Yaşargil Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Medical Faculty of Istanbul Atlas University (Number: E-22686390-050.99-26197; Date: April 12, 2023). Informed consent was obtained from all subjects and/or their legal guardian(s). Patients who were 12-years-old or older and diagnosed with VPS infecton in a University hospital between May 2006 and May 2019 were included in the present study. The study included 110 patients with SVPS infecton and 55 patients with RVPS infecton. Patients were divided into 2 groups as single (SVPS) infecton for history of only one infecton and as recurrent VPS infecton for more than one infection episode. Demographic and epidemiological data at the time of VPS infection diagnosis (age, gender, hydrocephalus etiology, type of hydrocephalus, history of previous shunt intervention, duration of prophylactic antibiotic use, reason of revision surgery, clinical and laboratory findings and medico-surgical approach data) were recorded on the prepared form. CSF, shunt catheter, shunt trace, wound on the scalp and intraabdominal fluid culture results were evaluated. Obtained cultures were identified based on the Clinical and Laboratory Standards Institute (CLSI) criteria. Microorganisms were identified through the Vitek 2 (Biomerieux) automated system and an antibiogram was performed to determine their sensitivity patterns. Each VPS infection was defined based on the following criteria: 1. Pathogen growth in the cultures obtained from the CSF or shunt equipment, and/or 2. Increase of cells in CSF (> 10/mm3), decreased CSF glucose (45 mg/dL) along with the presence of clinical symptoms such as fever, nausea-vomiting, headache, focal neurological deficits, and neck stiffness, despite the absence of pathogen growth in obtained cultures (16). After the routine blood tests and CSF sampling of patients with suspected VPS infection, empirical antibiotic treatment was initiated, then the surgical procedure was planned. In the two-stage shunt replacement, the infected shunt was removed and temporary drainage was provided with external ventricular drainage (EVD) until CSF sterilization was achieved. Then, a second shunt was inserted. Surgical procedures to externalize the distal shunt and re-internalize it after ensuring CSF sterilization with antibiotic treatment i) the shunt exchange (simultaneously removing the infected shunt and installing a new shunt) including i)the shunt exchange; removing the infected shunt installing a temporary EVD, and iii) replacing a new shunt after ensuring CSF sterilization. Empirical antibiotic treatment was revised based on the clinical outcomes and/or culture results. The patients who had shunt intervention, shunt revision, and infection at other hospitals and with an infection on the distal end of the shunt were excluded from the present study. Statistical Analyses Data was analyzed via SPSS 22.0 (SPSS Inc, Chicago, IL, USA) software for Windows. Categorical variables were comparatively analyzed through the χ2 test or Fisher exact test, whereas the Student-T test was employed for continuous variables. If normal distribution was not achieved, Mann-Whitney U test was used. Logistic regression analysis was performed to determine independent risk factors. P values lower than 0.05 was considered statistically significant. Results Demographic and epidemiological characteristics are summarized in Table 1 . Obstructive hydrocephalus and previous shunt intervention history were observed higher in the RVPS infection group (p < 0.05). The main indications for VPS surgery were shunt infection in the RVPS infection group and dysfunction of the shunt in the SVPS infecton group (p < 0.05). In both groups, shunt dysfunction was the indication for shunt surgery. However, the rate was higher in the RVPS infecton group (p < 0.05). Etiologies of hydrocephalus were central nervous system (CNS) malformation (32.3 %), CNS tumor nd cyst (23.9%), CNS tuberculosis (23.4%) and intracerebral hemorrhage (20.4) (Table 1 ). Overall, 34 of 165 patients died (20.6 %). Cultures wre obtained from 214 CSF, 36 shunt equipment, 32 wounds, and 19 intraabdominal fluid materials. Table 1 Demographic and Epidemiological Characteristics of Patients. SVPS (n = 110) RVPS (n = 125) P Patient age 33.4 ± 16.7 32.4 ± 15.9 0.826 Female/Male 50/60 (45/55) 57/68 (46/54) 0.136 Hydrocephalus etiology Intra cerebral hemorrhage 16 (14.5) 32 (25.6) 0.036 CNS tumor and cist 37 (33.6) 19 (15.2) 0.001 CNS Infections 13 (11.8) 42 (33.6) < 0.001 CNS malformation 44 (40) 32 (25.6) 0.019 Hydrocephalus Type 0.043 NPH 15 (13.7) 8 (6.4) 0.062 Obstructive hydrocephalus 65 (59) 92 (73.6) 0.018 Communicating hydrocephalus 30 (27.3) 25 ( 20 ) 0.189 Previous shunt insertion history 34 (30.9) 87 (69.6) < 0.001 Shunt revision history 79 (71.8) 102 (81.6) 0.075 Shunt revision reasons 0.003 Shunt infection 4 (3.6) 22 (17.6) 0.001 Shunt tip dislocation 12 (10.9) 10 ( 8 ) 0.445 Shunt Obstruction 18 (16.4) 13 (10.4) 0.178 Dysfunction 31(28.2) 30 ( 24 ) 0.446 CSF leakage 14 (12.7) 27 (21.6) 0.074 Prophylactic antibiotic duration (day) 2.6 ± 1.5 3.3 ± 2.2 0.014 Hospitalization (day) 21.4 ± 7.8 28.7 ± 10.6 < 0.001 Death ratios 12 (10.9) 22 (40) < 0.001 SVPS : single ventriculoperitoneal shunt; RVPSI : recurrent ventriculoperitoneal shunt; CNS : Central nervous system; NPH : Normal pressure hydrocephalus; CSF : cerebrospinal fluid, Data were expressed as mean ± SD. Diagnosis, clinical characteristics, and laboratory findings of patients are shown in Table 2 . Meningitis episodes occurred at 94.5% and 72% rates, while ventriculitis episodes occurred at 6.5% and 17% rates in SVPS infecton and RVPS infecton, respectively. As clinical characteristics, fever (≥ 38 C) is 44.9% and 55.1%, CNS infection findings is 46.2% and 53.8%, intraabdominal findings are 47.8% and 52.2%, local infection findings are 55.0% and 45.0 were find in SVPS infecton and RVPS infecton, respectively. CRP and CSF protein were found to be significantly higher in RVPS infecton than in SVPS infecton (< 0.026 and < 0.001, respectively). Table 2 Diagnosis, Clinic characteristics, and Laboratory Findings of Patients. SVPS (n = 110) RVPS (n = 125) p Diagnosis 0.036 Meningitis episodes 104 (94.5) 108 (72) Ventriculitis episodes 6 (6.5) 17 ( 18 ) Clinical characteristics Fever (≥ 38 C) 53 (44.9) 65 (55.1) 0.559 CNS infection findings 66 (46.2) 77 (53.8) 0.802 Intraabdominal findings 11 (47.8) 12 (52.2) 0.918 Local infection findings 22 (55.0) 18 (45.0) 0.254 Laboratory findings White Blood Cell (10 9 / L) 12.8 ± 6.7 12.7 ± 6.3 0.511 C-Reactive Protein (mg/L) 14.8 ± 17.5 18.3 ± 27.3 0.026 Blood glucose (mg/dL) 102 ± 27 101 ± 30 0.832 CSF glucose (mg/dL) 31 ± 17 30 ± 15 0.073 CSF protein (mg/dL) 127 ± 79 185 ± 104 < 0.001 Cell count of CSF ( /mm 3 ) 2114 ± 3556 2517 ± 4797 0.325 Data were expressed as mean ± SD. SVPSI : single ventriculoperitoneal shunt; RVPSI : recurrent ventriculoperitoneal shunt; CNS : Central nervous system; CSF : cerebrospinal fluid, Ninety microorganisms grew in 90 episodes in the RVS infecton group, while 73 microorganisms grew in 73 episodes in the SVP infecton group. Gram-negative bacillus growth (60%) was most common in RVPS infectons, while gram-positive coccal growth (60.3%) was predominant in SVPS infectons (p < 0.05) (Table 3 ). In the RVPS infecton group, methicillin resistance ratebetween staphylococci and third generation cephalosporin (3GCs), Piperacillin-tazobactam, and were statistically highercompared to the SVPS infecton group (p < 0.05) (Table 3 ). While 84% of patients were treated with combinationsof carbapenem in RVPS infecton, this rate was 49% in SVPI (p < 0.05) (Table 4 ). The duration of antibiotic use was shorter in the RVPS infecton group and the difference was statistically significant (p < 0.05) (Table 4 ). The rate of two stage shunt change was lowest in the VPS infecton group, while it was the highest in the SVPS infecton group (p < 0.05) (Table 4 ). Table 3 Grown microorganisms and resistance ratios in patients. SVPS (n = 110) RVPS (n = 125) P Type of grown pathogen 0.010 Gram positive bacteria 44 (60.3%) 33 ( 36.7%) 0.004 Gram negative bacteria 28 ( 38.3%) 54 (60.0%) 0.004 Candida spp. 1 (1.4) 3 (3.3 ) 0.378 Species CoNS 34 (46.6) 18 (20.0) S. aureus 7 (9.6) 5 (5.6) Streptococcus spp. 1 (1.4) 4 (4.4) Enterococcus spp. 2 (2.7) 6 (6.7) E.coli 9 (12.3) 13 (14.4) Pseudomonas spp. 9 (12.3) 22 (24.4) Klebsiella spp. 7 (9.6) 11 (12.2) Acinetobacter baumanni 3 (4.1) 8 (8.9) Resistance Meticiline in Staphylococci 25/41(61%) 20/23 (87%) 0.029 TGSS resistance 17 /28 (60.7%) 46/54 (85.2%) 0.013 Piperacilline-Tazobaktam 12/28 (42.9%) 45/54 (83.3%) < 0.001 Carbapenem 4 /28 (3.6%) 13/54 (10.4%) 0.011 SVPS ; single ventriculoperitonel shunt, RVPS ; recurrent ventriculoperitonel shunt, CoNS ; Coagulase-negative staphylococci, TGSS ; Third-generation cephalosporins, spp; species. Table 4 Antimicrobial treatment of patients. SVPS (n = 110) RVPS (n = 125) P Used Antibiotics Combinations without Carbapenem 54 (51%) 20 ( 16%) TGSS + Glycopeptide 38 10 Piperacillin - Tazobactam 5 4 Piperacillin- Tazobactam + Glycopeptide 13 6 Combinations with Carbapenem 54 (49%) 105 ( 84%) < 0.001 Carbapenem ± AG 18 19 Carbapenem + Glycopeptide 19 52 Carbapenem + Linezolid 8 11 Carbapenem + Colimycin ± AG 8 16 Carbapenem + Gylicopeptide + L-AmB - 6 Carbapenem + Linezolid + L-AmB 1 1 Duration of antibiotic use 21 ± 8 18 ± 6 0.003 Surgical Approach 0.001 No surgery 22 36 0.118 Insertion after extraction 20 35 0.076 One stage change 20 31 0.513 Two stage change 44 21 < 0.001 Extraction and No Insertion 4 2 0.323 SVPS , single ventriculoperitonel shunt; RVPS , recurrent ventriculoperitonel shunt; TGSS , Third-generation cephalosporins; AG , Aminoglycoside; L-AmB , Liposomal amphotericin B. Data were expressed as mean ± SD. In the group comparison, 10 of the variables were found to be statistically significant (previous shunt insertion, hydrocephalus etiology, type, shunt revision reasons, CSF protein, CRP, duration of prophylactic antibiotic use, growth of microorganisms and duration of antibiotics used for treatment, two-stage shunt change). When the logistic regression analysis was performed, the presence of prior shunt insertion, CSF protein, and total duration of antibiotics used for treatment were found to be independent risk factors. Discussion Recurrent VPS infection remains a major problem, and, unfortunately, there are not many studies on this topic. It is challenging to find detailed data on adult patients with VPS infecton in the literature ( 15 , 17 – 19 ). The current study examined the risk factors in the development of recurrent infection in adult patients with VPS and its management. This study included patients with single or recurrent infections. We observed that carbapenem has a powerful effect on recurrent infections. Use of long duration propylactic antibiotics may increase the recurrent infection risk. If the causative bacteria is gram positive, antibiotic treatment should be given for 14 days, but if it is gram negative, antibiotic treatment should be given for 21 days. In our cases, antibiotics were used for less than 21 days despite gram-negative growth. Several studies have reported certain etiological factors of hydrocephalus associated with increased rates of VPS infecton. In a study which investigated 1015 VP shunts, 70% of which were adults, congenital hyrocephalus was the most common etiology of hydrocephalus in those with VPS infecton, followed by hydrocephalus due to cerebral hemorrhage, post-traumatic, postcraniotomy and tumors / cysts ( 7 ). In another study examining 290 VPS and RVPS infectons in children, congenital malformations took the first place in the etiology of hydrocephalus, followed by CNS tumor and NS infections ( 8 ). Congenital malformations constituted the most common etiology of hydrocephalus in the SVPS infecton group, while CNS tuberculosis was the most common in the RVPS infecton group, in accordance with the studies in the literature. Hydrocephalus is one of the most common complications of tuberculous meningitis (TBM) ( 2 , 3 ). Simon et al. ( 3 ) found computer tomography (CT) evidence of hydrocephalus in 83% of 193 children with TBM. In a CT study, only three of 60 children and adults with TBM were found to have normal ventricles, giving an incidence of 95% ( 6 ). It has been reported that complications of shunt surgery are higher in patients with TBM than in patients with other conditions. The reasons for this are the poor general condition of these patients and also the presence of higher protein and cellular content in the CSF leading to more frequent shunt obstruction. Sacar et al. ( 21 ) reported shunt related complications in 11 (30%) children and three of 37 children that had to undergo multiple shunt revisions. Reddy et al. ( 7 ) reported that 26 of 114 (22.8%) patients had to undergo one or more shunt revisions while one patient required more than three revisions. Wang et al. ( 22 ) reported a shunt infection rate of 15.6% and revision rate of 43.8 % in their seriesof 37 children who underwent shunt surgery for TBM with hydrocephalus. Multiple revisions were done in 18.7% of patients. Shunt infection and erosion of skin over the shunt components are the other major complications of shunt surgery in poor grade patients with TBM and hydrocephalus. Mortality on long-term follow up has been reported to vary from 10.5–57.1% ( 23 ). To our knowledge, this is the first study to evaluate CNS tuberculosis and other etiological factors for hydrocephalus in the development of VPS infection. In our RVPS infection group, CNS tuberculosis was the most common etiology of hydrocephalus, and the rate of VPS infection episodes was higher in this etiologic group than in other etiologic groups. Consistent with the above studies, the rate of shunt revision history, mean CSF protein, and mortality rate were high in our RVPS infecton group. In addition, high CSF protein was found to be an independent risk factor for the development of RVPS infecton. Early diagnosis and treatment of CNS tuberculosis will prevent morbidity and mortality. Several studies indicated that obstructive hydrocephalus ( 7 ) and non-obstructive hydrocephalus ( 11 , 15 ) were risk factors for the development of VPS infecton. In the present study, obstructive hydrocephalus was found to be a risk factor in the development of recurrent VPS infecton. CSF leakage in children, especially after the closure of meningomyelocele, increases the risk of developing shunt infection ( 24 ). In a prospective study of 205 pediatric cases, it was determined that CSF leakage increased VPS infecton development by 27 times ( 24 ). The present study found that CSF infection was a risk factor for the development of RVPS infecton in adults. In a study that included pediatric patients, higher CSF protein level prior to VPS insertion was associated with a potential risk of re-infection VPS infecton ( 8 ). It was mentioned that high CSF protein levels were found to be associated with the develeopment of shunt reinfection ( 25 ). Similary, we observed higher CSF protein levels at the first episode diagnosis in the RVPS infecton group when compared to the single episode group. Higher CRP levels were associated with recurrent infections. In addition, CSF protein was found to be an independent risk factor. Common treatment recommendation for the prevention of VPS infection is a single dose of cefazolin ( 26 , 27 ). The present study established that prolonged use of prophylactic antibiotics was a risk factor in patients with recurrent infections. This may result in the use of antibiotics for a long time off-label that disrupt the intestinal flora of the patient and lead to resistant bacterial infections by colonization of hospital-acquired resistant bacteria. Such that, the bacteria grown in patients who developed RVPS infecton were hospital-borne resistant ( 28 ). VPS infecton is often caused by gram positives ( 29 ). However, several studies indicated increased rates of resistance and gram negative bacteria in recent years ( 8 , 21 , 22 , 30 ). Studies conducted in Turkey reported that 50% of the grown bacteria were gram-negative ( 21 , 22 ). Another study reported that 20 of the 46 grown bacteria belonged to the Staphylococcus strain and 65% of those were oxacillin resistant ( 22 ). In another study, cephalosporin sensitivity to gram-negative bacteria was determined to be 30 to 40% and carbapenem sensitivity was more than 60%. Similarly, cephalosporin susceptibility to gram positives decreased over the years while the susceptibility of teicoplanin and Linezolide was found to be more than 60% ( 30 ). According to our knowledge, the bacteria grown and the resistance states were not analyzed by comparison between single and recurrent infection periods. Similarly, we found increased gram-negative bacteria grown and increased resistance to the antibiotics in RVPS infection group. Carbepenem sensitivity was higher than the other agents for recurrent infections. Besides this, gram-negative bacteria grown and resistance to 3GCs are risk factors for recurrent infections. The American guidelines, without a recommendation regarding VPS infections, recommends the Health Care- and Device-Associated Central Nervous System Infections use of antibiotics for 10–14 days in the presence of gram-positive growths and 21 days in gram-negative growths. In the current study, gram-positive growths were prominent in the SVPS infection group and the duration of antibiotic use was consistent with the guideline recommendation, while gram-negative growths were prominent in the RVPS infecton group and the duration of antibiotic use was below the guideline recommendation. At the same time, short duration of antibiotic use was found to be an independent risk factor for the development of RVPS infecton. The medico-surgical approach (American guidelines and a few studies) recommend removal of the infected shunt and placement of temporary EVD until CSF sterilization and, if necessary, insertion of a new shunt and simultaneous glycopeptide plus 3GCs covering gram-negative and -positive bacteria ( 10 , 11 , 15 – 17 ). A study that examined 78 VPS infection episodes reported no relapses and re-infections in two-step shunt replacement, while recurrent infections were observed in other surgical procedures ( 15 ). Another study that focused on 86 VPS infection episodes indicated that minimum failure occured with the two-step shunt replacement employed via the medico-surgical approach ( 11 ). Another study, which examined 160 single episodes and 90 re-infections, mainly employed the combined treatment of vancomycin plus ceftriaxone, followed by vancomycin plus carbapenem ( 8 ). Similar to literature, the present study determined that low rates of two-step shunt replacement were a risk factor in R-VPS infection development. Because bacteria form a biofilm layer in the infected shunt, even if the infected CSF circulating in the shunt is treated, relapses of infection may occur due to bacteria released from the biofilm layer into the CSF. For this reason, in the two-stage change, the possibility of re-infection decreases as the infected shunt is removed, the CSF is sterilized before the second shunt is inserted, a temporary external ventricular drainage EVD is performed and then the shunt is inserted. However, in those whose infected shunt is not replaced, recurrence may occur because the biofilm layer remains. In a single-stage change, since the CSF is inserted without sterilization, it can re-infect the new shunt or form a new biofilm layer. The present study has several limitations. First, the APACHE score or severity of illness was not measured. The second limitation was the small sample size which led to inability in determining the individual effects of each broad spectrum antibiotic. Finally, the study was conducted in a single health care setting, thus our findings might not be generalizable to other health care environments. Single and recurrent VPS infecton are some of the most common and important complication of this intervention. Based on the findings of our study, it is essential to closely monitor patients with independent risk factors for RVPS infection development, due to the high rates of resistant gram negative bacterial growth and to initiate empirical antimicrobial treatment with glycopeptide plus carbapenem. Instead of 3GCs plus glycopeptide and such treatment options should be revised based on the clinical progress and microbiological culture results. More comprehensive information is needed to occur an effective algorithm for RVPS infecton management. Declarations Acknowledgement Not applicable. Funding The authors did not receive financial support for the research, authorship and/or publication of this article. Availability of Data and Materials Data is provided within the manuscript or supplementary information files. If needed, please contact with the corresponding author. The email address is [email protected] . Human Ethics and Consent to Participate Declarations The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Medical Faculty of Istanbul Atlas University (Number: E-22686390-050.99-26197; Date: April 12, 2023). Informed consent was obtained from all subjects and/or their legal guardian(s). Author Contributions Statement N.E., H.D., O.O, F.B., A.S. and H.U. wrote the main manuscript text and F.B. prepared tables 1-4. All authors reviewed the manuscript. Consent for publication Not applicable. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4792129","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":342299995,"identity":"fe627c1c-12cc-4f44-8745-012d5c87e3e1","order_by":0,"name":"Neval Elgormus","email":"","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":false,"prefix":"","firstName":"Neval","middleName":"","lastName":"Elgormus","suffix":""},{"id":342299996,"identity":"73a63e3e-6062-4b6a-816f-b35b0bac9cf3","order_by":1,"name":"Huseyin Dogu","email":"","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":false,"prefix":"","firstName":"Huseyin","middleName":"","lastName":"Dogu","suffix":""},{"id":342299997,"identity":"8dd86a95-f3fd-434c-bacc-1dd12aa899d8","order_by":2,"name":"Omer Okuyan","email":"","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":false,"prefix":"","firstName":"Omer","middleName":"","lastName":"Okuyan","suffix":""},{"id":342299998,"identity":"ff7ca478-05e2-4b19-8932-0ea1dac144ca","order_by":3,"name":"Fatma Bozkurt","email":"","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":false,"prefix":"","firstName":"Fatma","middleName":"","lastName":"Bozkurt","suffix":""},{"id":342299999,"identity":"da368678-bbc2-4173-88d4-ca45ff500397","order_by":4,"name":"Abdulhalim Senyigit","email":"","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":false,"prefix":"","firstName":"Abdulhalim","middleName":"","lastName":"Senyigit","suffix":""},{"id":342300000,"identity":"2b7e0650-bba3-4d4f-b8d5-da6f0bbad2b6","order_by":5,"name":"Hafize Uzun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBACAxDB+MdGzgDCtSBWS0OasQEDM4grQbSWw4kbwFoYiNBiLpH+TLpwx+H07ez9Rzf8KJBg4G/vTsCrxXJGQpr0zDPpuTt7DrPd7AE6TOLM2Q34HXYj4Zg0D5t17oYbyWw3eIBaDCRyCWlJbANqYU43AGq5+Yc4Lcls0rxtzgkgxm3ibDnzjNma50ya4YYzh81uyxhI8BD2y/H0h7d5KmzkDY43Prv5Bhin/O29+LVgAB7SlI+CUTAKRsEowAoAdWdFH7YjkpcAAAAASUVORK5CYII=","orcid":"","institution":"İstanbul Atlas University","correspondingAuthor":true,"prefix":"","firstName":"Hafize","middleName":"","lastName":"Uzun","suffix":""}],"badges":[],"createdAt":"2024-07-24 03:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4792129/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4792129/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64827535,"identity":"25338f07-8f82-4724-97ae-36a6a3508f57","added_by":"auto","created_at":"2024-09-19 08:58:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":677537,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4792129/v1/6ef0edc4-b935-42e5-9ec3-f9da4348e1bf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Risk Factors for Recurrent Ventriculoperitoneal Shunt Infections in Adult","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHydrocephalus, enlargement of the intraventricular system and subarachnoid space, is a pathological clinical process that may result as a complication of intracranial haemorrhage, tumour, infection, or brain injury (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). For management of this complication, ventriculoperitoneal shunt (VPS) is used to decrease the intracranial pressure. However, the risk of postoperative infection is high which may lead to unsuccessful outcome and intracranial infection. The management of VPS infecton is crucial because of its life threatening progress (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors for shunt infection have been previously shunt-associated infection, revision of dysfunctional shunts and postoperative cerebrospinal fluid (CSF) leakage (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). There are very few studies on the evaluation of risk factors and treatment approach related to recurrent VPS (RVPS) infection. Non-standard use of antibiotics and inadequate guideline for management of VPS infection can lead to an increase in antibiotic resistance and recurrent infections (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRisk factors in the literature are usually different in pediatric and adult cases. In pediatric cases, gender, age at shunt insertion (young age; \u0026lt;6 months), preterm birth, immune status, etiology of hydrocephalus, type of hydrocephalus, recent shunt revision, previous shunt infection, opening of the skin at the shunt insertion or incision site, CSF leakage from the incision site, prolonged operation time, surgeon experience, lack of prophylactic perioperative antibiotics, and use of neuroendoscope during the operation are the main risk factors (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Major risk factors in adult cases are infection of the previous shunt, revision of the shunt for dysfunction, multiple revisions, CSF leakage from the post-operative skin incision, advancing age (advanced age), operation time, surgeon's experience, and use of neuroendoscope (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the present study, we aimed to retrospectively analyze a large series of patients who experienced long term proximal VPS infections, to describe the epidemiological, clinical, laboratory, and microbiological characteristics and treatment outcomes, and to identify the risk factors for recurrent-infection in adults.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis case-control study was conducted at the Istanbul Atlas University, Medicine Hospital, \u0026nbsp;Department of Infectious Diseases and Clinical Microbiology, and University of Health Science, Gazi Yaşargil Education and Research Hospital, Department of Infectious Diseases and Clinical Microbiology. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Medical Faculty of Istanbul Atlas University (Number: E-22686390-050.99-26197; Date: April 12, 2023). Informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003ePatients who were\u0026nbsp;12-years-old\u0026nbsp;or older and diagnosed with VPS infecton in a University hospital between May 2006 and May 2019 were included in the present study. The study included 110 patients with SVPS infecton and 55 patients with RVPS infecton. Patients were\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;divided into 2 groups\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp;as single (SVPS) infecton for history of only one infecton and\u0026nbsp;as\u0026nbsp;recurrent VPS infecton for more than one infection episode. Demographic and epidemiological data at the time of VPS infection diagnosis (age, gender, hydrocephalus etiology, type of hydrocephalus, history of previous shunt intervention, duration of prophylactic antibiotic use, reason of revision surgery, clinical and laboratory findings and medico-surgical approach\u0026nbsp;data)\u0026nbsp;were recorded on the prepared form. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCSF, shunt catheter, shunt trace,\u0026nbsp;wound\u0026nbsp;on the scalp and intraabdominal fluid culture results were evaluated. Obtained cultures were identified based on the Clinical and Laboratory Standards Institute (CLSI) criteria. Microorganisms were identified through the Vitek 2 (Biomerieux) automated system and an antibiogram was performed to determine their sensitivity patterns. Each VPS infection was defined based on the following criteria:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1. Pathogen growth in the cultures obtained from the CSF or shunt equipment, and/or\u003c/p\u003e\n\u003cp\u003e2. Increase of cells in CSF (\u0026gt; 10/mm3), decreased CSF glucose (45 mg/dL) along with the presence of clinical symptoms such as fever, nausea-vomiting, headache, focal neurological deficits, and neck stiffness, despite the absence of pathogen growth in obtained cultures (16). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the routine blood tests and CSF sampling of patients with suspected VPS infection, empirical antibiotic treatment was initiated,\u0026nbsp;then the surgical procedure was planned.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the two-stage shunt replacement, the infected shunt was removed\u0026nbsp;and temporary drainage was provided with external ventricular drainage (EVD) until CSF sterilization was achieved. Then, a second shunt was inserted. Surgical procedures to externalize the distal shunt and re-internalize it after ensuring CSF sterilization with antibiotic treatment\u0026nbsp; \u0026nbsp; \u0026nbsp;i) the shunt exchange (simultaneously removing the infected shunt and installing a new shunt)\u0026nbsp;including\u0026nbsp;i)the shunt exchange; removing the infected shunt installing a temporary EVD,\u0026nbsp;and iii) replacing a new shunt after ensuring CSF sterilization. Empirical antibiotic treatment was revised based on the clinical outcomes and/or culture results. The patients who had shunt intervention, shunt revision, and infection at other hospitals and with an infection on the distal end of the shunt were excluded from the present study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData was analyzed via SPSS 22.0 (SPSS Inc, Chicago, IL, USA) software for Windows. Categorical variables were comparatively analyzed through the \u0026chi;2 test or Fisher exact test,\u0026nbsp;whereas the Student-T test was employed for continuous variables. If normal distribution was not achieved, Mann-Whitney U test was used. Logistic regression analysis was performed to determine independent risk factors. \u003cem\u003eP\u003c/em\u003e values lower than 0.05 was considered statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic and epidemiological characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Obstructive hydrocephalus and previous shunt intervention history were observed higher in the RVPS infection group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The main indications for VPS surgery were shunt infection in the RVPS infection group and dysfunction of the shunt in the SVPS infecton group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In both groups, shunt dysfunction was the indication for shunt surgery. However, the rate was higher in the RVPS infecton group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Etiologies of hydrocephalus were central nervous system (CNS) malformation (32.3 %), CNS tumor nd cyst (23.9%), CNS tuberculosis (23.4%) and intracerebral hemorrhage (20.4) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Overall, 34 of 165 patients died (20.6 %). Cultures wre obtained from 214 CSF, 36 shunt equipment, 32 wounds, and 19 intraabdominal fluid materials.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Epidemiological Characteristics of Patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVPS (n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale/Male\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50/60 (45/55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57/68 (46/54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHydrocephalus etiology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntra cerebral hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCNS tumor and cist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCNS Infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCNS malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHydrocephalus Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstructive hydrocephalus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92 (73.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunicating hydrocephalus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious shunt insertion history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (30.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShunt revision history\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShunt revision reasons\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShunt infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShunt tip dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.445\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShunt Obstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31(28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.446\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSF leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProphylactic antibiotic duration (day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6 \u0026plusmn; 1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3 \u0026plusmn; 2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospitalization (day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeath ratios\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSVPS\u003c/b\u003e: single ventriculoperitoneal shunt; \u003cb\u003eRVPSI\u003c/b\u003e: recurrent ventriculoperitoneal shunt; \u003cb\u003eCNS\u003c/b\u003e: Central nervous system; \u003cb\u003eNPH\u003c/b\u003e: Normal pressure hydrocephalus; \u003cb\u003eCSF\u003c/b\u003e: cerebrospinal fluid,\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDiagnosis, clinical characteristics, and laboratory findings of patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Meningitis episodes occurred at 94.5% and 72% rates, while ventriculitis episodes occurred at 6.5% and 17% rates in SVPS infecton and RVPS infecton, respectively. As clinical characteristics, fever (\u0026ge;\u0026thinsp;38 C) is 44.9% and 55.1%, CNS infection findings is 46.2% and 53.8%, intraabdominal findings are 47.8% and 52.2%, local infection findings are 55.0% and 45.0 were find in SVPS infecton and RVPS infecton, respectively. CRP and CSF protein were found to be significantly higher in RVPS infecton than in SVPS infecton (\u0026lt;\u0026thinsp;0.026 and \u0026lt;\u0026thinsp;0.001, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnosis, Clinic characteristics, and Laboratory Findings of Patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRVPS (n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeningitis episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (94.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentriculitis episodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever (\u0026ge;\u0026thinsp;38 C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (55.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.559\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCNS infection findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.802\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraabdominal findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal infection findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaboratory findings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite Blood Cell (10\u003csup\u003e9\u003c/sup\u003e / L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.511\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-Reactive Protein (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.026\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood glucose (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u0026thinsp;\u0026plusmn;\u0026thinsp;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101\u0026thinsp;\u0026plusmn;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSF glucose (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026thinsp;\u0026plusmn;\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 \u0026plusmn; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSF protein (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127\u0026thinsp;\u0026plusmn;\u0026thinsp;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185\u0026thinsp;\u0026plusmn;\u0026thinsp;104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCell count of CSF ( /mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2114\u0026thinsp;\u0026plusmn;\u0026thinsp;3556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2517\u0026thinsp;\u0026plusmn;\u0026thinsp;4797\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSVPSI\u003c/b\u003e: single ventriculoperitoneal shunt; \u003cb\u003eRVPSI\u003c/b\u003e: recurrent ventriculoperitoneal shunt; \u003cb\u003eCNS\u003c/b\u003e: Central nervous system; \u003cb\u003eCSF\u003c/b\u003e: cerebrospinal fluid,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNinety microorganisms grew in 90 episodes in the RVS infecton group, while 73 microorganisms grew in 73 episodes in the SVP infecton group. Gram-negative bacillus growth (60%) was most common in RVPS infectons, while gram-positive coccal growth (60.3%) was predominant in SVPS infectons (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the RVPS infecton group, methicillin resistance ratebetween staphylococci and third generation cephalosporin (3GCs), Piperacillin-tazobactam, and were statistically highercompared to the SVPS infecton group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). While 84% of patients were treated with combinationsof carbapenem in RVPS infecton, this rate was 49% in SVPI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The duration of antibiotic use was shorter in the RVPS infecton group and the difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The rate of two stage shunt change was lowest in the VPS infecton group, while it was the highest in the SVPS infecton group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGrown microorganisms and resistance ratios in patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of grown pathogen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram positive bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (60.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 ( 36.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram negative bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 ( 38.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCandida spp.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.3 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (46.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eS. aureus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStreptococcus spp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus spp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas spp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (24.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella spp.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAcinetobacter baumanni\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResistance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMeticiline in Staphylococci\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25/41(61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20/23 (87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTGSS resistance\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 /28 (60.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46/54 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePiperacilline-Tazobaktam\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/28 (42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45/54 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCarbapenem\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 /28 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13/54 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSVPS\u003c/b\u003e; single ventriculoperitonel shunt, \u003cb\u003eRVPS\u003c/b\u003e; recurrent ventriculoperitonel shunt, \u003cb\u003eCoNS\u003c/b\u003e; Coagulase-negative staphylococci, \u003cb\u003eTGSS\u003c/b\u003e; Third-generation cephalosporins, spp; species.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAntimicrobial treatment of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRVPS\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;125)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsed Antibiotics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCombinations without Carbapenem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 ( 16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTGSS\u0026thinsp;+\u0026thinsp;Glycopeptide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin - Tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin- Tazobactam\u0026thinsp;+\u0026thinsp;Glycopeptide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCombinations with Carbapenem\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 ( 84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;\u0026plusmn;\u0026thinsp;AG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;+\u0026thinsp;Glycopeptide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;+\u0026thinsp;Linezolid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;+\u0026thinsp;Colimycin\u0026thinsp;\u0026plusmn;\u0026thinsp;AG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;+\u0026thinsp;Gylicopeptide\u0026thinsp;+\u0026thinsp;L-AmB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarbapenem\u0026thinsp;+\u0026thinsp;Linezolid\u0026thinsp;+\u0026thinsp;L-AmB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of antibiotic use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e21\u0026thinsp;\u0026plusmn;\u0026thinsp;8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical Approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsertion after extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne stage change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo stage change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtraction and No Insertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.323\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eSVPS\u003c/b\u003e, single ventriculoperitonel shunt; \u003cb\u003eRVPS\u003c/b\u003e, recurrent ventriculoperitonel shunt; \u003cb\u003eTGSS\u003c/b\u003e, Third-generation cephalosporins; \u003cb\u003eAG\u003c/b\u003e, Aminoglycoside; \u003cb\u003eL-AmB\u003c/b\u003e, Liposomal amphotericin B.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the group comparison, 10 of the variables were found to be statistically significant (previous shunt insertion, hydrocephalus etiology, type, shunt revision reasons, CSF protein, CRP, duration of prophylactic antibiotic use, growth of microorganisms and duration of antibiotics used for treatment, two-stage shunt change). When the logistic regression analysis was performed, the presence of prior shunt insertion, CSF protein, and total duration of antibiotics used for treatment were found to be independent risk factors.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRecurrent VPS infection remains a major problem, and, unfortunately, there are not many studies on this topic. It is challenging to find detailed data on adult patients with VPS infecton in the literature (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The current study examined the risk factors in the development of recurrent infection in adult patients with VPS and its management. This study included patients with single or recurrent infections. We observed that carbapenem has a powerful effect on recurrent infections. Use of long duration propylactic antibiotics may increase the recurrent infection risk. If the causative bacteria is gram positive, antibiotic treatment should be given for 14 days, but if it is gram negative, antibiotic treatment should be given for 21 days. In our cases, antibiotics were used for less than 21 days despite gram-negative growth.\u003c/p\u003e \u003cp\u003eSeveral studies have reported certain etiological factors of hydrocephalus associated with increased rates of VPS infecton. In a study which investigated 1015 VP shunts, 70% of which were adults, congenital hyrocephalus was the most common etiology of hydrocephalus in those with VPS infecton, followed by hydrocephalus due to cerebral hemorrhage, post-traumatic, postcraniotomy and tumors / cysts (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In another study examining 290 VPS and RVPS infectons in children, congenital malformations took the first place in the etiology of hydrocephalus, followed by CNS tumor and NS infections (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Congenital malformations constituted the most common etiology of hydrocephalus in the SVPS infecton group, while CNS tuberculosis was the most common in the RVPS infecton group, in accordance with the studies in the literature. Hydrocephalus is one of the most common complications of tuberculous meningitis (TBM) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Simon et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) found computer tomography (CT) evidence of hydrocephalus in 83% of 193 children with TBM. In a CT study, only three of 60 children and adults with TBM were found to have normal ventricles, giving an incidence of 95% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). It has been reported that complications of shunt surgery are higher in patients with TBM than in patients with other conditions. The reasons for this are the poor general condition of these patients and also the presence of higher protein and cellular content in the CSF leading to more frequent shunt obstruction. Sacar et al. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) reported shunt related complications in 11 (30%) children and three of 37 children that had to undergo multiple shunt revisions. Reddy et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) reported that 26 of 114 (22.8%) patients had to undergo one or more shunt revisions while one patient required more than three revisions. Wang et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) reported a shunt infection rate of 15.6% and revision rate of 43.8 % in their seriesof 37 children who underwent shunt surgery for TBM with hydrocephalus. Multiple revisions were done in 18.7% of patients. Shunt infection and erosion of skin over the shunt components are the other major complications of shunt surgery in poor grade patients with TBM and hydrocephalus. Mortality on long-term follow up has been reported to vary from 10.5\u0026ndash;57.1% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). To our knowledge, this is the first study to evaluate CNS tuberculosis and other etiological factors for hydrocephalus in the development of VPS infection. In our RVPS infection group, CNS tuberculosis was the most common etiology of hydrocephalus, and the rate of VPS infection episodes was higher in this etiologic group than in other etiologic groups. Consistent with the above studies, the rate of shunt revision history, mean CSF protein, and mortality rate were high in our RVPS infecton group. In addition, high CSF protein was found to be an independent risk factor for the development of RVPS infecton. Early diagnosis and treatment of CNS tuberculosis will prevent morbidity and mortality.\u003c/p\u003e \u003cp\u003eSeveral studies indicated that obstructive hydrocephalus (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and non-obstructive hydrocephalus (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) were risk factors for the development of VPS infecton. In the present study, obstructive hydrocephalus was found to be a risk factor in the development of recurrent VPS infecton. CSF leakage in children, especially after the closure of meningomyelocele, increases the risk of developing shunt infection (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In a prospective study of 205 pediatric cases, it was determined that CSF leakage increased VPS infecton development by 27 times (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The present study found that CSF infection was a risk factor for the development of RVPS infecton in adults. In a study that included pediatric patients, higher CSF protein level prior to VPS insertion was associated with a potential risk of re-infection VPS infecton (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It was mentioned that high CSF protein levels were found to be associated with the develeopment of shunt reinfection (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Similary, we observed higher CSF protein levels at the first episode diagnosis in the RVPS infecton group when compared to the single episode group. Higher CRP levels were associated with recurrent infections. In addition, CSF protein was found to be an independent risk factor.\u003c/p\u003e \u003cp\u003eCommon treatment recommendation for the prevention of VPS infection is a single dose of cefazolin (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The present study established that prolonged use of prophylactic antibiotics was a risk factor in patients with recurrent infections. This may result in the use of antibiotics for a long time off-label that disrupt the intestinal flora of the patient and lead to resistant bacterial infections by colonization of hospital-acquired resistant bacteria. Such that, the bacteria grown in patients who developed RVPS infecton were hospital-borne resistant (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVPS infecton is often caused by gram positives (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, several studies indicated increased rates of resistance and gram negative bacteria in recent years (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Studies conducted in Turkey reported that 50% of the grown bacteria were gram-negative (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study reported that 20 of the 46 grown bacteria belonged to the Staphylococcus strain and 65% of those were oxacillin resistant (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In another study, cephalosporin sensitivity to gram-negative bacteria was determined to be 30 to 40% and carbapenem sensitivity was more than 60%. Similarly, cephalosporin susceptibility to gram positives decreased over the years while the susceptibility of teicoplanin and Linezolide was found to be more than 60% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). According to our knowledge, the bacteria grown and the resistance states were not analyzed by comparison between single and recurrent infection periods. Similarly, we found increased gram-negative bacteria grown and increased resistance to the antibiotics in RVPS infection group. Carbepenem sensitivity was higher than the other agents for recurrent infections. Besides this, gram-negative bacteria grown and resistance to 3GCs are risk factors for recurrent infections. The American guidelines, without a recommendation regarding VPS infections, recommends the Health Care- and Device-Associated Central Nervous System Infections use of antibiotics for 10\u0026ndash;14 days in the presence of gram-positive growths and 21 days in gram-negative growths. In the current study, gram-positive growths were prominent in the SVPS infection group and the duration of antibiotic use was consistent with the guideline recommendation, while gram-negative growths were prominent in the RVPS infecton group and the duration of antibiotic use was below the guideline recommendation. At the same time, short duration of antibiotic use was found to be an independent risk factor for the development of RVPS infecton.\u003c/p\u003e \u003cp\u003eThe medico-surgical approach (American guidelines and a few studies) recommend removal of the infected shunt and placement of temporary EVD until CSF sterilization and, if necessary, insertion of a new shunt and simultaneous glycopeptide plus 3GCs covering gram-negative and -positive bacteria (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A study that examined 78 VPS infection episodes reported no relapses and re-infections in two-step shunt replacement, while recurrent infections were observed in other surgical procedures (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Another study that focused on 86 VPS infection episodes indicated that minimum failure occured with the two-step shunt replacement employed via the medico-surgical approach (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Another study, which examined 160 single episodes and 90 re-infections, mainly employed the combined treatment of vancomycin plus ceftriaxone, followed by vancomycin plus carbapenem (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Similar to literature, the present study determined that low rates of two-step shunt replacement were a risk factor in R-VPS infection development. Because bacteria form a biofilm layer in the infected shunt, even if the infected CSF circulating in the shunt is treated, relapses of infection may occur due to bacteria released from the biofilm layer into the CSF. For this reason, in the two-stage change, the possibility of re-infection decreases as the infected shunt is removed, the CSF is sterilized before the second shunt is inserted, a temporary external ventricular drainage EVD is performed and then the shunt is inserted. However, in those whose infected shunt is not replaced, recurrence may occur because the biofilm layer remains. In a single-stage change, since the CSF is inserted without sterilization, it can re-infect the new shunt or form a new biofilm layer.\u003c/p\u003e \u003cp\u003eThe present study has several limitations. First, the APACHE score or severity of illness was not measured. The second limitation was the small sample size which led to inability in determining the individual effects of each broad spectrum antibiotic. Finally, the study was conducted in a single health care setting, thus our findings might not be generalizable to other health care environments.\u003c/p\u003e \u003cp\u003eSingle and recurrent VPS infecton are some of the most common and important complication of this intervention. Based on the findings of our study, it is essential to closely monitor patients with independent risk factors for RVPS infection development, due to the high rates of resistant gram negative bacterial growth and to initiate empirical antimicrobial treatment with glycopeptide plus carbapenem. Instead of 3GCs plus glycopeptide and such treatment options should be revised based on the clinical progress and microbiological culture results. More comprehensive information is needed to occur an effective algorithm for RVPS infecton management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive financial support for the research, authorship and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript or supplementary information files. If needed, please contact with the corresponding author. The email address is [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the Medical Faculty of Istanbul Atlas University (Number: E-22686390-050.99-26197; Date: April 12, 2023). Informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.E., H.D., O.O, F.B., A.S. and H.U. wrote the main manuscript text and F.B. prepared tables 1-4. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no potential conflicts of interest with respect to the research, authorship and/or publication of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKestle JR, Drake JM, Cochrane DD, et al. Lack of benefit of endoscopic ventriculoperitoneal shunt insertion: a multicenter randomized trial. J Neurosurg. 2003;98:284\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimon TD, Hall M, Riva-Cambrin J, et al. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. Clinical article. J Neurosurg Pediatr. 2009;4:156\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimon TD, Kronman MP, Whitlock KB, et al. Reinfection after treatment of first cerebrospinal fluid shunt infection: a prospective observational cohort study. J Neurosurg Pediatr. 2018;21:346\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuan TJ, Thorell EA, Hamblett NM, Kestle JR, Rosenfeld M, Simon TD. Treatment and microbiology of repeated cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J. 2011;30:731\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimon TD, Hall M, Dean JM, Kestle JR, Riva-Cambrin J. Reinfection following initial cerebrospinal fluid shunt infection. J Neurosurg Pediatr. 2010;6:277\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKestle JRW, Garton HJL, Whitehead WE, Drake JM, Kulkarni AV, Cochrane DD, Muszynski C, Walker ML. Management of shunt infections: A multicenter pilot study. J Neurosur. 2006;105(Suppl 3):177\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy GK, Bollam P, Caldito G. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg. 2012;78:155\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYakut N, Soysal A, Kepenekli Kadayifci E, et al. Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study. Br J Neurosurg. 2018;32:196\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeelani NU, Kulkarni AV, Desilva P, Thompson DN, Hayward RD. Postoperative cerebrospinal fluid wound leakage as a predictor of shunt infection: a prospective analysis of 205 cases. Clinical article. J Neurosurg Pediatr. 2009;4:166\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017;64:e34\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePelegr\u0026iacute;n I, Lora-Tamayo J, G\u0026oacute;mez-Junyent J, et al. Management of Ventriculoperitoneal Shunt Infections in Adults: Analysis of Risk Factors Associated With Treatment Failure. Clin Infect Dis. 2017;64:989\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta D, Sekar A, Guruprasad N, Bansal S. Shunt Migration in Children: A Patient Level Systematic Review of Risk Factors and Outcome. Neurol India. 2022;70(5):1780\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg. 2001;94(2):195\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy GK, Bollam P, Caldito G. Ventriculoperitoneal shunt surgery and the risk of shunt infection in patients with hydrocephalus: long-term single institution experience. World Neurosurg. 2012;78(1\u0026ndash;2):155\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis. 2008;47(1):73\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmadvand S, Dayyani M, Etemadrezaie H, et al. Rate and Risk Factors of Early Ventriculoperitoneal Shunt Revision: A Five-Year Retrospective Analysis of a Referral Center. World Neurosurg. 2020;134:e505\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrame PT, McLaurin RL. Treatment of CSF shunt infections with intrashunt plus oral antibiotic therapy. J Neurosurg. 1984;60:354\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon der Brelie C, Simon A, Gr\u0026ouml;ner A, Molitor E, Simon M. Evaluation of an institutional guideline for the treatment of cerebrospinal fluid shunt-associated infections. Acta Neurochir (Wien). 2012;154:1691\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanev PM, Sheehan JM. Reflections on shunt infection. Pediatr Neurosurg. 2003;39:285\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGirt MJ, Zaas A, Fuchs HE, George TM, Kaye K, Sexton DJ. Risk factors for pediatric ventriculoperitoneal shunt infection and predictors of infectious pathogens. Clin Infect Dis. 2003;36:858\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSacar S, Turgut H, Toprak S, et al. A retrospective study of central nervous system shunt infections diagnosed in a university hospital during a 4-year period. BMC Infect Dis. 2006;6:43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang KW, Chang WN, Shih TY, et al. Infection of cerebrospinal fluid shunts: causative pathogens, clinical features, and outcomes. Jpn J Infect Dis. 2004;57:44\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajshekhar V. Management of hydrocephalus in patients with tuberculous meningitis. Neurol India. 2009;57:368\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClemmensen D, Rasmussen MM, Mosdal C. A retrospective study of infections after primary VP shunt placement in the newborn with myelomeningocele without prophylactic antibiotics. Childs Nerv Syst. 2010;26:1517\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGutierrez-Murgas Y, Snowden JN. Ventricular shunt infections: Immunopathogenesis and clinical management. J Neuroimmunol. 2014;276(1\u0026ndash;2):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195\u0026ndash;283.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerr\u0026iacute;os-Torres SI, Umscheid CA, Bratzler DW et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017 [published correction appears in JAMA Surg. 2017;152(8):803]. JAMA Surg. 2017;152:784\u0026ndash;791.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTischendorf J, de Avila RA, Safdar N. Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review. Am J Infect Control. 2016;44:539\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorking Group on Neurosurgical Outcomes Monitoring, Woo PY, Wong HT, et al. Primary ventriculoperitoneal shunting outcomes: a multicentre clinical audit for shunt infection and its risk factors. Hong Kong Med J. 2016;22:410\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar V, Shah AS, Singh D, Loomba PS, Singh H, Jagetia A. Ventriculoperitoneal shunt tube infection and changing pattern of antibiotic sensitivity in neurosurgery practice: Alarming trends. Neurol India. 2016;64:671\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ventriculoperitoneal shunt, infection, resistant gram-negative bacteria, carbapenem","lastPublishedDoi":"10.21203/rs.3.rs-4792129/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4792129/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: The objective of this paper is to evaluate demographic, clinical, laboratory and microbiological features of ventriculoperitoneal shunt (VPS) infections in this 13 year retrospective study. VPS-related bacterial agents and their antibiotic sensitivity were also investigated in single VPS (SVPS) and recurrent VPS (RVPS) infections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The study included 110 patients with SVPS infection and 55 patients with RVPS infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In patients who developed multiple infections, gram-negative organisms were the most predominant (60%, 54/90). Resistance rates were 85.2% for third generation cephalosporins, 83.3% for Piperacillin-Tazobactam, and 10.4% for Carbapenem's. Forty-nine % of patients in the SVPS and 84.4% in the RVPS infection group were treated with combinations of carbapeneme. Central nervous system (CNS) tuberculosis as the etiology of hydrocephalus, short duration of antibiotics used for treatment, high cerebrospinal fluid (CSF) protein and blood C-reactive protein (CRP) levels, and prolonged use of prophylactic antibiotics was found related to increased rate of recurrent infection occurrence. Two-stage shunt change decreased the risk of recurrent infections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e VPS infection may be life-threating and its management rucial. Rational and appropriate use of antibiotics and treatment methods according to the algorithms can reduce recurrent infections. Gram-negative predominant bacterial colonization and its carbapenem sensitivity in RVPS infection has to be kept in mind to manage the infection effectively.\u003c/p\u003e","manuscriptTitle":"Evaluation of Risk Factors for Recurrent Ventriculoperitoneal Shunt Infections in Adult","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-26 14:51:34","doi":"10.21203/rs.3.rs-4792129/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9e01c39-20bc-4b3d-83a9-f9bb0c705b3c","owner":[],"postedDate":"August 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-19T08:50:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-26 14:51:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4792129","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4792129","identity":"rs-4792129","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}