An Outbreak After All: Among Pediatric Patients with Cerebrospinal Fluid Diversion Device Infections Highlights Gaps in Guidelines

Overview

Journal Antimicrob Steward Healthc Epidemiol

Publisher Cambridge University Press

Specialty Infectious Diseases

Date 2024 Sep 18

PMID 39290624

Authors

Felicia Scaggs Huang

Cameron Griffin

Matthew Fenchel

Melanie DuBose

Andrea Ankrum

Joshua K Schaffzin

Affiliations

Soon will be listed here.

Abstract

Objective: is normal skin flora but can cause sterile implant infections. We investigated a cluster of seven patients with in anaerobic cerebrospinal fluid (CSF) cultures in November 2020. Further analysis identified a missed outbreak, highlighting ambiguity in diagnosis of indolent organisms in the 2017 IDSA meningitis guidelines.

Design: Outbreak investigation.

Setting: Quaternary pediatric facility.

Patients: A case was defined as a hospitalized patient with isolated from CSF culture from January 1, 2016 to December 31, 2022.

Methods: We defined comparison periods based on timing of culture positivity as 1) pre-outbreak (2016-2020), 2) outbreak (2020-2021), and 3) post-outbreak (2022). Rates of positive cultures per 1000 CSF cultures and rate ratios were calculated by comparison periods.

Results: We identified 9 positive CSF cultures among 7 cases November 10-27, 2020, all with at least 1 CSF diversion device. The anaerobic culture media was substituted at the time of case cluster. In 2021, the culture media was implemented permanently with no increase in culture positivity. The rate of positive CSF cultures and rate ratio increased in the outbreak period (p=0.01) compared to pre-outbreak and post-outbreak periods. There was no difference between the pre- and post-outbreak periods.

Conclusions: Retrospective analysis of CSF culture data led to reclassifying a pseudo-outbreak as a true outbreak in CSF diversion devices at our institution. Clearer guidance is needed to delineate the role of in CSF diversion device infections.

References

Walters B, Hoffman H, HENDRICK E, Humphreys R . Cerebrospinal fluid shunt infection. Influences on initial management and subsequent outcome. J Neurosurg. 1984; 60(5):1014-21. DOI: 10.3171/jns.1984.60.5.1014. View

Nisbet M, Briggs S, Ellis-Pegler R, Thomas M, Holland D . Propionibacterium acnes: an under-appreciated cause of post-neurosurgical infection. J Antimicrob Chemother. 2007; 60(5):1097-103. DOI: 10.1093/jac/dkm351. View

Teoh Z, Ankrum A, Meinzen-Derr J, Weingartner M, Goebel M, Scaggs Huang F . An outbreak of at a quaternary children's hospital linked to equipment reprocessing. Infect Control Hosp Epidemiol. 2022; 44(8):1267-1273. PMC: 11151214. DOI: 10.1017/ice.2022.235. View

Bignardi G . Risk factors for Clostridium difficile infection. J Hosp Infect. 1998; 40(1):1-15. DOI: 10.1016/s0195-6701(98)90019-6. View

Simon T, Kronman M, Whitlock K, Gove N, Browd S, Holubkov R . Variability in Management of First Cerebrospinal Fluid Shunt Infection: A Prospective Multi-Institutional Observational Cohort Study. J Pediatr. 2016; 179:185-191.e2. PMC: 5123958. DOI: 10.1016/j.jpeds.2016.08.094. View

Kulkarni A, Rabin D, Drake J . Repeat cerebrospinal fluid shunt infection in children. Pediatr Neurosurg. 2001; 35(2):66-71. DOI: 10.1159/000050393. View

Tunkel A, Hasbun R, Bhimraj A, Byers K, Kaplan S, Scheld W . 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017; 64(6):e34-e65. PMC: 5848239. DOI: 10.1093/cid/ciw861. View

Westergren H, Westergren V, Forsum U . Propionebacterium acnes in cultures from ventriculo-peritoneal shunts: infection or contamination?. Acta Neurochir (Wien). 1997; 139(1):33-6. DOI: 10.1007/BF01850865. View

Chatzopoulos K, Shannon S, Schuetz A . Clinical utility of anaerobic culture of cerebrospinal fluid. Anaerobe. 2020; 64:102246. DOI: 10.1016/j.anaerobe.2020.102246. View

10.

EVERETT E, Eickhoff T, Simon R . Cerebrospinal fluid shunt infections with anaerobic diphtheroids (Propionibacterium species). J Neurosurg. 1976; 44(5):580-4. DOI: 10.3171/jns.1976.44.5.0580. View

11.

Brook I . Meningitis and shunt infection caused by anaerobic bacteria in children. Pediatr Neurol. 2002; 26(2):99-105. DOI: 10.1016/s0887-8994(01)00330-7. View

12.

Brook I, Frazier E . Infections caused by Propionibacterium species. Rev Infect Dis. 1991; 13(5):819-22. DOI: 10.1093/clinids/13.5.819. View

13.

Carter J, Langley J, Kuhle S, Kirkland S . Risk Factors for Central Venous Catheter-Associated Bloodstream Infection in Pediatric Patients: A Cohort Study. Infect Control Hosp Epidemiol. 2016; 37(8):939-945. DOI: 10.1017/ice.2016.83. View

14.

Tamber M, Klimo Jr P, Mazzola C, Flannery A . Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 8: Management of cerebrospinal fluid shunt infection. J Neurosurg Pediatr. 2015; 14 Suppl 1:60-71. DOI: 10.3171/2014.7.PEDS14328. View

15.

Vinchon M, Dhellemmes P . Cerebrospinal fluid shunt infection: risk factors and long-term follow-up. Childs Nerv Syst. 2006; 22(7):692-7. DOI: 10.1007/s00381-005-0037-8. View

16.

Simon T, Butler J, Whitlock K, Browd S, Holubkov R, Kestle J . Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr. 2014; 164(6):1462-8.e2. PMC: 4035376. DOI: 10.1016/j.jpeds.2014.02.013. View

17.

Arnell K, Cesarini K, Lagerqvist-Widh A, Wester T, Sjolin J . Cerebrospinal fluid shunt infections in children over a 13-year period: anaerobic cultures and comparison of clinical signs of infection with Propionibacterium acnes and with other bacteria. J Neurosurg Pediatr. 2008; 1(5):366-72. DOI: 10.3171/PED/2008/1/5/366. View

18.

McAlpine A, Robinson J, Barton M, Balamohan A, Davies H, Skar G . Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study. Pediatr Infect Dis J. 2022; 41(6):449-454. DOI: 10.1097/INF.0000000000003513. View