Canadian Nosocomial Infection Surveillance Program

2011 SURVEILLANCE FOR HEALTHCARE ACQUIRED CEREBROSPINAL FLUID SHUNT ASSOCIATED INFECTIONS

January 12, 2011

FINAL

Contact:

Robyn Mitchell

Senior Epidemiologist

Canadian Nosocomial Infections Surveillance Program

Public Health Agency of Canada

Phone:(514) 496-5910

Email:

Canadian Nosocomial Infections Surveillance Program (CNISP)

2011 SURVEILLANCE FOR HEALTHCARE ACQUIRED CEREBROSPINAL FLUID SHUNT ASSOCIATED INFECTIONS

Working Group: Y. Chagla, J. Embree, S. Forgie, J. Langley (Chair), A. Matlow,

R. Mitchell, D. Moore

Table of Contents

I.Summary of changes from the 2010 protocol

II.Introduction

III.Objectives

IV.Methodology

  1. Surveillance design
  2. Eligibility to participate
  3. Surveillance period
  4. Numerator data
  5. Denominator data
  6. Data collection and reporting
  7. Analysis

V.Ethics

VI.References

Appendices

  1. Patient questionnaire
  2. Instructions for completing the patient questionnaire
  3. Quarterly denominatorforms

2011 SURVEILLANCE FOR HEALTHCARE ACQUIRED CEREBROSPINAL FLUID SHUNT ASSOCIATED INFECTIONS

I. SUMMARY OF CHANGES

  • Q8 of the patient questionnaire. Option changed from“revision of an existing shunt” to“revision of an existinginternalized shunt”
  • Four quarterly denominator forms are provided (Appendix C)

II. INTRODUCTION

A prospective surveillance system to determine the incidence of infections associated with cerebrospinal fluid (CSF) shunting devices in patients admitted to hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) network has been ongoing since January 2006. Infections arising in the year after shunt surgery are considered surgical site infections (SSI).

The CNISP is a collaborative effort of the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada and the Centre for Communicable Diseases and Infection Control (CCDIC) of the Public Health Agency of Canada (PHAC). Established in 1994, the objectives of CNISP are to provide rates and trends of healthcare-associated infections at Canadian healthcare facilities, thus enabling comparison of rates (benchmarks), and providing evidence-based data that can be used in the development of national guidelines on clinical issues related to healthcare-associated infections. At present, 56 sentinel hospitals from 9 provinces participate in the CNISP network.

The establishment of this CSF shunt infection surveillance protocol followed a three-year project in which extensive patient-related data were collected from 21 hospitals. That project identified higher rates in children than in adults and variations in compliance with antimicrobial therapy.1

Placement of a CSF shunt is the most commonly performed neurosurgical procedure in North America. Between 1982 and 1983 in Canada, 1,973 new shunts were placed and 1,189 revised, of which 85% were ventriculoperitoneal.2 Shunt placement is the primary treatment for hydrocephalus, an enlargement of the cerebroventricular system resulting from failure of CSF drainage.3 Surgical decompression diverts CSF from the ventricular system to another body compartment, most commonly the peritoneal cavity, by means of a silicone or polyethylene tube or “shunt”.

The most common complication of CSF shunt surgery is infection, with rates varying from 1% to 18% in the literature.4-11The National Healthcare Safety Network in the United States reported pooled mean rates of 4.04 to 5.93 cases of infection per 100 procedures, depending on the risk category.12

Risk factors for CSF shuntinfection includeprevious shunt-associated infection, shunt revision for dysfunction, postoperative CSF leakage, advanced age or patient pre-maturity, duration of the shunt placement operation, experience of the neurosurgeon and use of a neuroendoscope.4,13 Insertions are linked with seizures, higher future risks of shunt infections and malfunction, and reduced IQ and school performance.10

III. OBJECTIVES

  1. To determine the incidence of CSF shunt infections in patients of all ages admitted to Canadian hospitals participating in the CNISP (that is, the number of infections occurring in the first year after initial placement of an internalized shunting device).
  1. To describe the microbiologic epidemiology of CSF shunt infections in all patients with a) new shunts and/or b) revisions to an existing internalized shunt.

IV. METHODOLOGY

A.Surveillance design

Ongoing, prospective surveillance of infections following placement of an internalized CSF shunt or revision or other surgical manipulation of an existing shunt.

B.Eligibility to participate

1. Hospitals which are part of the CNISP network

2. Hospitals which are able to perform year-round surveillance for CSF shunt-associated infections

3. Hospitals which are able to collect and submit the data as outlined in the protocol.

C.Surveillance period

The surveillance period will include all CSF shunt placement or revision procedures performed from January 1, 2011 to December 31, 2011. Infections that develop within 12 months of procedure will be included and reported retrospectively based on the date of procedure.

  1. Numerator data

Case definition:

A CSF shunt infectionis defined as:

An episode in which a bacterial or fungal pathogen(s) is isolated from the cerebrospinal fluid AND is associated with at least ONE of the following:

(a)fever (temperature ≥38ºC),

OR

(b)neurological signs or symptoms,

OR

(c)abdominal signs or symptoms,

OR

(d)signs or symptoms of shunt malfunction or obstruction

Relapse vs. new infection

Re-infectionof a shunt is an infectious episode occurring after diagnosis of a CSF shunt infection and/or completion of antibiotic therapy with a CSF bacterial or fungal isolate different from the previous infection. Such a patient would be eligible to be counted as a new CSF healthcare-associated infection.

Relapse of a shunt infection is an infectious episode occurring within 1 month of completion of therapy with an isolate of the same genus. This event is not eligible to be counted as a new CSF healthcare-associated infection.

Exclusions:

  • Patients with transcutaneous or external shunting devices or non-shunting devices (e.g. Ommaya reservoir) are not eligible for enrolment,
  • Patients whose CSF was culture-positive (bacterial or fungal) at the time of placement of the shunt are not eligible for enrolment
  • If the device in place at the time theinfection is diagnosed wasnot placed at the hospital where the infection was identified, the hospital should not report the infection
  • If the surgery occurred more than 12 months before the infection was identified
  1. Denominator data

Each participating facility will submit the total number of surgical placements for new CSF shunts, the number of surgical revisions to existing CSF shunts as well as the total number of CSF shunt surgeries for those less than 18 years of age and for those greater to or equal to 18 years of ageperformed during the surveillance period (Appendix C). Denominator data will be submitted to Katie Cassidy at the address belowon a quarterly basis as per the schedule:

Period / Surveillance Period / Date of data submission
First / Jan 1 – Mar 31, 2011 / June 1, 2011
Second / Apr 1 – June 30, 2011 / Sept 1, 2011
Third / Jul 1 – Sept 30, 2011 / Dec 1, 2011
Fourth / Oct 1 – Dec 31, 2011 / Mar 1, 2012

F.Data collection and reporting

Patients with a CSF shunt associated infectionwill be identified through review of positive CSF cultures from the microbiology laboratory. Once a positive culture is identified, a chart (health record) review will be conducted to determine if the device associated with that culture was placed at the hospital the infection was identified and that the surgery occurred in the previous 12 months. If the device associated with that culture was not placed at the hospital where the infection was identified, the hospital should not report this infection.

Each time an infection is identified a patient questionnaire will be completed (Appendix A). All completed forms will bemailed or faxed to the address belowon a quarterly basis:

Katie Cassidy

Public Health Agency of Canada

Blood Safety and Surveillance/Healthcare-Associated Infections Division

Centre for Communicable Diseases and Infection Control

100 Eglantine Driveway, A.L. 0601E2

Ottawa, ON, K1A 0L2

Fax: (613) 946-0678

  1. Analysis:

Incidence of shunt infections/100 shunt surgeries will be reported. Summary descriptions of the infected patients will include frequency estimates of gender, age, infecting agent, time of infection since surgery. PHAC will be responsible for annual reporting to institutions of their local rates and adult/pediatric-stratified national rates.

V. ETHICS

This surveillance may or may not require approval for the institutional review board(IRB) at each participating site, depending on whether the data collected are part of the hospital’s routine infection control program, and depending on whether ethics approval is needed for participation in CNISP data sharing. Each facility will be responsible for obtaining IRB approval if needed.

VI.References

1. Langley JM, Gravel D, Moore D, Matlow A, Embree J, MacKinnon-Cameron D, Conly J; Canadian Nosocomial Infection Surveillance Program. Study of cerebrospinal fluid shunt-associated infections in the first year following placement, by the Canadian Nosocomial Infection Surveillance Program. Infect Control Hosp Epidemiol. 2009;30:285-8.

2. Hoffman SM. The use of shunting devices for cerebrospinal fluid in Canada. J Can Neurol Sciences 1986;13:81.

3. Patwardhan RV, Nanda A. Implanted ventricular shunts in the United States: the billion-dollar-a-year cost of hydrocephalus treatment. Neurosurgery 2005; 56:139-144

4. Kulkarni AV, Drake JM, Lamberti-Pasculli M. Cerebrospinal fluid shunt infection: a prospective study of risk factors. J Neurosurg 2001;94(2):195-201

5. Simon TD, Hall M, Riva-Cambrin J, Albert E, Jeffries HE, LaFleur B et al. Infection rates following initial cerebrospinal fluid shunt placement across pediatric hospitals in the United States. J Neurosurg Pediatrics 2009;4:156-165

6. Simon TD, Hall M, Dean JM, Kestle JRW, Riva-Cambrin J, Hydrocephalus Clinical Research Network. Reinfection following initial cerebrospinal fluid shunt infection. J Neurosurg Pediatrics. 2010;6(3):277-285

7. Cochrane DD and Kestle J. Ventricular shunting for hydrocephalus in children: patients, procedures, surgeons and institutions in English Canada, 1981-2001. Eur JPediatr Surg. 2002; 12 Suppl 1:S6-11

8. Faillace WJ. A no-touch technique protocol to diminish cerebrospinal fluid shunt infection. Surg Neurol 1995;43(4):344-50

9. Baird C, O’Connor D and Pittman T. Late shunt infections. Pediatr Neurosurg 1999:31(5):269-73

10. Kanev PM and Sheehan JM. Reflections on shunt infection. Pediatr Neurosurg 2003;39(6):285-90

11.McClelland S and HallWA. Postoperative Central Nervous System Infection: Incidence and Associated Factors in 2111 Neurosurgical Procedures. Clin Infect Dis 2007;45:55-9

12. National Healthcare Safety Network (NHSH) report: Data summary for 2006 through to 2008, issued December 2009. Am J Infect Control 2009; 37:783:805

13. Conen 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; 47:73-82

Appendix A –2011 CSF shunt patient questionnaire

1.CHEC Site: ______2.Unique Patient ID: ______
3. Date of birth _____/______/______OR Age ______
(dd/mmm/yyyy) e.g. 17/Jan/2010 □ Years □ Months □ Days
4. Gender Male Female
5. Pathogen(s) isolated (please check all that apply):
Alpha hemolytic Streptococcus Propionibacterium species
Coagulase negative Staphylococcus sp Pseudomonas aeruginosa
Corynebacterium species Staphylococcus aureus
Escherichia coli S. Epidermis
Haemophilus influenzae type B Other, please specify:______
6. Date of CSF shunt procedure _____/______/______
(dd/mmm/yyyy) e.g. 17/Jan/2010
7. Date positive CSF culture was obtained _____/______/______
(dd/mmm/yyyy) e.g. 17/Jan/2010
8.The shunt surgery was: (please check one the following):
revision of an existing internal shunt
placement of entirely new shunt
10.Type of CSF shunt inserted was: (please check one the following):
VP (ventriculoperitoneal)
VA (ventriculoatrial)
LP (lumbo-peritoneal)
Other (please specify): ______

Please mail or fax all completed patient questionnaires quarterlyto:

Katie Cassidy

Public Health Agency of Canada

Blood Safety and Surveillance/Healthcare-Associated Infections Division

Centre for Communicable Diseases and Infection Control

100 Eglantine Driveway, A.L. 0601E2

Ottawa, ON, K1A 0L2

Phone: (613) 954-1718

Fax: (613) 946-0678

Email:

Period / Surveillance Period / Date of data submission
First / Jan 1 – Mar 31, 2011 / June 1, 2011
Second / Apr 1 – June 30, 2011 / Sept 1, 2011
Third / Jul 1 – Sept 30, 2011 / Dec 1, 2011
Fourth / Oct 1 – Dec 31, 2011 / Mar 1, 2012

2011 SURVEILLANCE FOR HEALTHCARE ACQUIRED CEREBROSPINAL FLUID SHUNT ASSOCIATED INFECTIONS

Appendix B - Instructions on Completing Patient Questionnaire (Appendix A)

Q1. CHEC site

This will be the 3-character alphanumeric number assigned to your institution. It will always begin with the two digit number assigned to your CHEC member e.g., 07, 15, and a letter assigned by the CHEC member for that specific institution e.g., A, B, C, etc. The CHEC Site # for each institution should always be the same for all the CHEC/CNISP surveillance projects and will always have all three alphanumeric digits reported as the CHEC Site #, e.g., 07A, 15A.

Q2. Unique patient identifier

This number should never be longer than 8 characters. The 8 characters should consist of the 3 character CHEC site # (e.g., 09A), the surveillance year (e.g., 11), and a consecutive number starting at 001 and continuing on with each additional case. An example of the first case in an Institution would be 09A11001. An example of the thirty-fifth case would be 09A11035, and so on. Use the same number with a lower case letter at the end if >1 SSI occurs following the same surgery e.g., 07A11001a).

Note: Please do not include dashes as separators in between the sets of characters

Q3. Date of birth (DOB)

Please enter Day (##), Month (May) and Year (1947) in this order. If the date of birth is not available please enter the patient’s age (in years, months or days).

Q4. Gender

Check male or female gender as appropriate.

Q5. Pathogen(s) isolated

Please list all microorganisms isolated for the CSF shunt infection as reported by the laboratory. If ‘other’ pathogen is checked, please specify the organism in the text field.

Q6.Date of CSF shunt procedure

Please enter Day (##), Month (May) and Year (2011) in this order.

Q7. Date positive CSF culture was obtained

Please enter the date the positive CSF culture was obtainedDay (##), Month (May) and Year (2011).

Q8. Type of shunt surgery

Please indicate whether the surgery was for the revision of an existing internal shunt or the placement of an entirely new shunt. For shunt removal please check revision of an exiting shunt. Please check only ONE box.

Q9. Type of CSF shunt inserted

Please indicate the type of CSF shunt system inserted (i.e. ventriculoperitoneal, ventriculoatrial, lumbo-peritoneal shunt or other). If other, please specify in the text field.

Appendix C – 2011 CSF shunt denominator form (Q1)

CHEC #: ______

Please provide the following information for the period from January 1, 2011 to March 31, 2011:

Total number of surgical placements
Number of surgical placements of new CSF shunts
Number of surgical revisions to existing CSF shunts
18 years of age
< 18 years of age

Please fax or mail denominator informationto:

Katie Cassidy

Phone: (613) 954-1718

Fax: (613) 946-0678

Email:

Appendix C – 2011 CSF shunt denominator form (Q2)

CHEC #: ______

Please provide the following information for the period from April 1, 2011 to June 30, 2011:

Total number of surgical placements
Number of surgical placements of new CSF shunts
Number of surgical revisions to existing CSF shunts
18 years of age
< 18 years of age

Please fax or mail denominator information to:

Katie Cassidy

Phone: (613) 954-1718

Fax: (613) 946-0678

Email:

Appendix C – 2011 CSF shunt denominator form (Q3)

CHEC #: ______

Please provide the following information for the period from July 1, 2011 to September 30, 2011:

Total number of surgical placements
Number of surgical placements of new CSF shunts
Number of surgical revisions to existing CSF shunts
18 years of age
< 18 years of age

Please fax or mail denominator information to:

Katie Cassidy

Phone: (613) 954-1718

Fax: (613) 946-0678

Email:

Appendix C – 2011 CSF shunt denominator form (Q4)

CHEC #: ______

Please provide the following information for the period from October 1, 2011 to December 31, 2011:

Total number of surgical placements
Number of surgical placements of new CSF shunts
Number of surgical revisions to existing CSF shunts
18 years of age
< 18 years of age

Please fax or mail denominator information to:

Katie Cassidy

Phone: (613) 954-1718

Fax: (613) 946-0678

Email:

1

January 12, 2011