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: robyn.mitchell@phac-aspc.gc.ca 1 January 12, 2011 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 A. Surveillance design B. Eligibility to participate C. Surveillance period D. Numerator data E. Denominator data F. Data collection and reporting G. Analysis V. Ethics VI. References Appendices A. Patient questionnaire B. Instructions for completing the patient questionnaire C. Quarterly denominator forms 2 January 12, 2011 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 existing internalized 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 threeyear 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.4-11 The 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 shunt infection include previous shunt-associated infection, shunt revision for dysfunction, postoperative CSF leakage, advanced age or patient prematurity, duration of the shunt placement operation, experience of the neurosurgeon 3 January 12, 2011 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). 2. 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 shuntassociated 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. 4 January 12, 2011 D. Numerator data Case definition: A CSF shunt infection is 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: fever (temperature ≥38º C), OR neurological signs or symptoms, OR abdominal signs or symptoms, OR signs or symptoms of shunt malfunction or obstruction (a) (b) (c) (d) Relapse vs. new infection Re-infection of 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 the infection is diagnosed was not 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 E. 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 age performed during the surveillance period 5 January 12, 2011 (Appendix C). Denominator data will be submitted to Katie Cassidy at the address below on a quarterly basis as per the schedule: Period First Second Third Fourth Surveillance Period Jan 1 – Mar 31, 2011 Apr 1 – June 30, 2011 Jul 1 – Sept 30, 2011 Oct 1 – Dec 31, 2011 Date of data submission June 1, 2011 Sept 1, 2011 Dec 1, 2011 Mar 1, 2012 F. Data collection and reporting Patients with a CSF shunt associated infection will 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 be mailed or faxed to the address below on 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 D. 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. 6 January 12, 2011 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 J Pediatr 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 Hall WA. 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 7 January 12, 2011 Appendix A – 2011 CSF shunt patient questionnaire 1. CHEC Site: ________________________ 2. Unique Patient ID: _________________ 3. Date of birth OR _____/______/________ (dd/mmm/yyyy) e.g. 17/Jan/2010 4. Gender 5. Male Age ___________ □ Years □ Months □ Days Female Pathogen(s) isolated (please check all that apply): Alpha hemolytic Streptococcus Coagulase negative Staphylococcus sp Corynebacterium species Escherichia coli Haemophilus influenzae type B 6. Date of CSF shunt procedure Propionibacterium species Pseudomonas aeruginosa Staphylococcus aureus S. Epidermis Other, please specify:_________________ _____/______/________ (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): __________________________________________ 8 January 12, 2011 Please mail or fax all completed patient questionnaires quarterly to: 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: katie.cassidy@phac-aspc.gc.ca Period First Second Third Fourth Surveillance Period Jan 1 – Mar 31, 2011 Apr 1 – June 30, 2011 Jul 1 – Sept 30, 2011 Oct 1 – Dec 31, 2011 Date of data submission June 1, 2011 Sept 1, 2011 Dec 1, 2011 Mar 1, 2012 9 January 12, 2011 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 thirtyfifth 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 obtained Day (##), Month (May) and Year (2011). 10 January 12, 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. 11 January 12, 2011 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 information to: Katie Cassidy Phone: (613) 954-1718 Fax: (613) 946-0678 Email: katie.cassidy@phac-aspc.gc.ca 12 January 12, 2011 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: katie.cassidy@phac-aspc.gc.ca 13 January 12, 2011 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: katie.cassidy@phac-aspc.gc.ca 14 January 12, 2011 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: katie.cassidy@phac-aspc.gc.ca 15 January 12, 2011