Study: Ritual catheter change unwarranted
Synopsis: Daily incidence of ventriculitis in patients with ventriculostomies rose to a peak at 10 days. However, the data suggest that routine change of the catheter in an attempt to prevent infection is not warranted.
Source: Holloway KL, et al. Ventriculostomy infections: The effect of monitoring duration and catheter exchange in 584 patients. J Neurosurg 1996; 85:410-424.
Holloway and colleagues report the results of a retrospective analysis of ventriculostomy infections from data collected as part of a multicenter study of head injuries. The report is based on 584 patients who received 712 ventricular catheters, each of which was placed under sterile conditions at either the bedside or in the operating room and was tunneled for a short distance under the skin. Cerebrospinal fluid (CSF) was only collected for culture when clinically indicated. Patients were monitored for a mean duration of 7.5 days, and individual catheters remained in place for a mean of 5.06 days (range, <1 hour to 34.3 days). Sixty-one patients (10.4%) developed ventriculitis, defined by a positive culture or a predominantly (>50%) neutrophilic pleocytosis with total WBC higher than 50/mm3 or glucose less than 15 mg/dL.
Multivariate analysis revealed that the following were independently associated with risk of ventriculitis: septicemia, pneumonia, craniotomy, intraventricular hemorrhage, and the presence of a depressed skull fracture requiring surgery (P values for each ranging from 0.001 to 0.007). Among the variables examined, those not associated with increased risk of ventriculitis were corticosteroid administration and presence of air in the ventricles. The daily rate of infection for all catheters rose progressively, reaching a peak at day 10. This finding was true when only first catheters were analyzed as well. The mean time to detection of infection was 6.7 days. Most cases of septicemia and of pneumonia also occurred in the first 10 days. Ninety-seven patients had their catheter changed at least once. The incidence of ventriculitis in patients whose longest period of individual catheter residence was less than 5 days was 13%, while it was 18% in those with a greater duration of residence; these results were not significantly different.
Comment by Stan Deresinski, MD, FACP, clinical professor of medicine at Stanford University and associate chief of infectious diseases at Santa Clara Valley Medical Center, San Jose, CA:
Monitoring of intracranial pressure is commonly performed in settings in which this pressure is elevated, and it is believed that interventions to lower it are beneficial. While several types of devices are used for intracranial pressure monitoring, the placement of ventricular catheters provides the opportunity to reduce intracranial pressure by drainage of CSF. A downside of the use of indwelling ventricular catheters is, however, a significant risk of ventriculitis.
The 10.4% incidence of infection in this series is within the range of risk reported in other studies. The factors associated with an increased risk of infection were bacteremic or pulmonary infection, intracranial hemorrhage, craniotomy, and depressed fracture requiring surgery. It is of interest that corticosteroid use was not associated with an increased incidence of ventriculitis.
There is no analysis of prior antibiotic use as either a risk or confounding factor. The authors do not provide information about the bacteriology, the management, or the outcome of these infections, except to indicate that three patients with infection died, while 73 without infection did so. The time to death, and therefore duration of risk of ventriculitis, is not provided, however. The optimal statistical approach to evaluating the risk of infection would have been a Kaplan-Meier analysis.
Routine ventricular catheter exchange at five-day intervals in order to decrease the risk of ventriculitis has previously been recommended (Mayhall GG, et al. N Engl J Med 1984; 310:553-559). Unfortunately, this recommendation has never been put to the critical test of a prospective, randomized clinical trial. As the authors conclude, however, their data argue against this recommendation. They found that there was no significant difference in the incidence of infection of individual catheters with residence of less than five days when compared to those with a longer duration in place. Thus, they conclude that routine catheter replacement is not warranted.
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