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
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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
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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
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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.
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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
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(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.
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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
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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): __________________________________________
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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
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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).
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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.
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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
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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
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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
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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
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January 12, 2011