Evidentiary table 1
PICO Questions: Is there an increased risk of adverse mechanical or infectious events in adult patients undergoing EVD insertion
outside the OR? In adult patients undergoing EVD insertion, does the risk of adverse events vary depending on the training,
procedural experience or specialty of the clinician performing the procedure?
Reference Patient Underlying Study
[ #]
number Clinical
Design
Condition(s)
13
188
2, 3, 4, 6
CS-R
Gardner
2009
Endpoint
Findings
Quality
Post-procedural
hemorrhage
following EVD
insertion in OR
vs outside OR
No significant
difference in
post-procedural
hemorrhages
whether the
EVD was
placed in the
OR versus ICU
low
21
Foreman
2015
To compare
safety and
accuracy of
placement
between EVDs
placed in the
ICU versus OR
Complications
low
of hemorrhage,
infection, and
non-functional
drains may be
mitigated by
ventriculostomy
placement in
the OR.
150
1-6
CS-R
Comments
Patients who
underwent
ventriculostomy
placement in
the ICU
differed in
important ways
(i.e. indication
for placement
and the
administration
of pre-
procedure
prophylactic
antibiotics)
from patients
treated in the
OR
12
Kakarla
2008
346
1, 2, 8
CS-R
To study the
safety and
accuracy of
ventriculostomy
by
neurosurgical
trainees
8 O’Neill
2008
29
1, 2, 5, 6, 7
CS-R
To evaluate
accuracy and
complication
rates of EVD
insertions by
nonneurosurgeons
Neither the
moderate
resident's
training
experience nor
the side of
placement
seemed to
affect accuracy
No significant
low
Mixed
differences in
population of
complication
EVD and
rates relative to
fiberoptic ICP
neurosurgical
monitors
series when
EVD performed
by nonneurosurgeons
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Evidentiary table #2
PICO Question: In adult patients undergoing EVD insertion, does the risk of adverse events vary depending on the
training, procedural experience, or specialty of the clinician performing the procedure?
Reference Patient Underlying
[ #]
number Clinical
Condition(s)
33
728
Craniotomy,
Pollock
shunt,
JR 2001
Spinal
surgery,
stereotactic
bx
35
29
1, 2, 3, 5, 6,
Ehtisham
2009
Study Endpoint
Design
Findings
Quality
CS-R
Surgical AEs in
relation to #
assisted cases
Inverse relation
between
number of
assisted cases
and rate of AEs
low
CS-R
EVD-related
AEs
low
12
Kakarla
2008
CS-R
Accuracy of
placement, AEs
1 infection
(3.4%), 5
catheter tract
hematomas
<5cc (20.7%)
when EVD
inserted by NI
Supervised
junior trainee
AE rates same
as experienced
residents
346
1, 2, 3, 4, 8
Comments
low
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
AEs=Adverse Events, NI=neurointensivist
Evidentiary table #3
PICO Question: What is the risk of bleeding with insertion of an EVD?
Reference
[ #]
Patient Underlying Study Endpoint
number Clinical
Design
Condition(s)
346
1, 2, 3, 8
CS-R
Placement
accuracy and
AEs
Findings
Quality
Comments
4
sympto
matic
bleeds
low
No risk factors for
bleeding were
identified
#35 Ehtisham
2009
29
1, 2, 3, 4, 5,
6, 8
CS-R
Placement
accuracy and
AEs
low
All procedures by
neurointensivist.
#11 Maniker 2006
160
1, 2, 3, 4, 5,
7
CS-R
Hemorrhagic
AEs
low
#13 Gardner 2009
188
1, 2, 3, 4, 6
CS-R
Hemorrhagic
AEs
0
sympto
matic
bleeds
4
sympto
matic
bleeds
77
(41%)
bleeds
#44 Naff 2011
48
1, 3
R
AEs
28%
low
(for
sympto
matic
bleeds)
Non-significant
increase in bleeding
with smaller diameter
catheter
MR showed many
bleeds, most small. 1
required surgery.
Overall symptomatic
bleeds unknown
rtPA dose escalation.
#12 Kakarla 2008
low
# 43 Dey 2015
250
1, 3
R
Bleeding,
infection
16.8%
bleeds,
2.4%
sympto
matic
low
CLEAR-III ongoing.
Blinded for rtPA vs
placebo reduced
evidence quality for
bleeding outcome
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial, AE=adverse events
Evidentiary table #4
PICO Question: What procedural factors are associated with a decreased risk of catheter malposition?
Reference Patient Underlyin
[ #]
number g Clinical
Condition(
s)
12
346
1,2,3,4,8
Kakarla
2008
Study
Design
Endpoint
Findings
Quality
Comments
CS-R
77% ideal
10% functional
13% malposition
low
Freehand
placement
47 Patil
2013
109
1,2,3,4,5,7
CS-R
Devised
grading
system for
accuracy of
positioning
Malposition
rates
low
Freehand
placement
48
Bergdal
2013
147
1,2,3,4,5
CS-R
Correct
EVD
placement
low
Bolt with
freehand
placement or
freehand alone
49
Huyette
2008
50
Abdoh
2012
97
1,2,3,4,5
CS-R
Catheter
positioning
low
Freehand at
bedside
66
2,3
CS-R
Catheter
positioning
79% ideal;
TBI indication less
often associated with
ideal placement
Bolted EVDs more
accurate, and
associated with
lower reoperation
rates.
22.4% malposition
rate, only 56% in
target location
4% extraventricular,
20% contralateral
low
Freehand
bedside
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
AEs=Adverse Events, NI=neurointensivist
Evidentiary table #5
PICO Question: In adult patients requiring EVD, what is the optimal method and timing of VTE prophylaxis?
Reference
[ #]
Patient
number
Underlying
Clinical
Condition(s)
Risk of Hemorrhage with Prophylaxis
#88
100
Craniotomy
Macdonald
2003
Study Design
Endpoint
Findings
Quality
Comments
Pilot single
center RCT
DVT/PE
within 1
month
No significant
differences in
rates of DVT
(0% vs 2%) or
hemorrhage (2%
vs 4%) in
patients between
heparin or
LMWH VTE
prophylaxis
starting at the
time of surgery
No significant
differences
in the incidence
of new
hemorrhages
(19.6% vs
16.3%),
radiographicallysignificant
hemorrhages
(1.8% vs. 7.3%)
and clinically
significant
hemorrhages
(1.8% vs.3.6%)
between patients
Low
Underpowered
to detect small
differences in
clinically
significant
endpoint
Postoperative
intracranial
hemorrhage
#14
Tanweer
2013
99
1,2,3,4,5,6
CS-R
EVDassociated
hemorrhage
LOW
starting heparin
prophylaxis
within 24 hours
or after 24 hours
Grad[14]uated Compression Stockings (GCS)
#76
2518
Ischemic
Multicenter
CLOTS
stroke,
RCT
trial 1
hemorrhagic
2009
stroke
#62
Agnelli
1998
307
5
(patients
undergoing
elective
neurosurgery)
Multicenter
RCT
Proximal
DVT
No significant
difference in
DVT with thigh
length stockings.
Significant
increase in skin
breakdown with
stockings (odds
ratio 4.2, 95%
CI 2.4-7.3)
Moderate
Establishes
potential harm
from graduated
compression
stockings in
comparable
population
Symptomatic
PE or any
DVT within 8
days
Decreased rate
of DVT in
patients
receiving
LMWH + GCS
compared to
GCS alone (32%
vs. 17%;
p<0.01)
High
GCS alone
associated with
high rate of
DVT, which is
substantially
reduced by
addition of
LMWH
prophylaxis
Low
True efficacy in
reducing PE in
neurosurgical
patients not
No significant
difference in
major or minor
bleeding
between groups
Inferior Vena Cava (IVC) Filters
#84
400
Patients with
Decousus
proximal
1998
DVT
Multicentre
RC: pts
randomized to
anticoagulation
PE within
first 12 days
of
randomization
No difference in
PE at 2 years
with IVC added
to
+ IVC filter
OR
anticoagulation
alone
Intermittent Pneumatic Compression
#78
2876
Ischemic
Dennis
stroke,
2013
hemorrhagic
stroke
Multicenter
RCT
anticoagulation
clear as all
patients in this
study received
anticoagulation.
At 8 years
follow up:
Decrease in PE
with IVC filter
(6.2% vs.
15.1%; p<0.01)
Increased DVT
with IVC filter
(35.7 vs. 27.5%;
p=0.04)
No difference in
mortality
Proximal
DVT within
30 days
Decreased VTE
with IPC
(adjusted OR
0·65 [95% CI
0·51–0·84])
Increased skin
breakdown with
IPC (3% vs. 1
%; p<0.01)
However utility
in primary
prophylaxis
may be limited
by associated
increase in
subsequent
DVT
Moderate
Establishes
efficacy of IPC
at preventing
VTE in
comparable
population;
with associated
small risk but
significant risk
of skin
breakdown.
Trend towards
decreased
mortality with
IPC (11% vs.
13%; p=0.06)
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Evidentiary table 6
PICO Question: Infection Introduction
Reference Patient Underlying
[ #]
number Clinical
Condition(s)
#97
34
3,6
Chan
1988
#98
87
1,2,3,4,5,8
Omar
2010
Study Endpoint Findings
Design
Quality Comments
CS-P
VL
VRI
No
infections
Unique, experimental
EVD system
32% VRI
VL
VRI definition: (+)
total, 52%
culture AND (+) gram
with VRI
stain AND CSF changes
after 10
(WBC>11, glucose<25,
days
protein>40)
#101
172
2,3,4,5
CS-P
VRI
Risk(life
VL
VRI definition: (+)
Mayhall
table) of
culture 24h after
1984
infection:
insertion
D#5=9%,
D#8=21%,
D#10=37%,
D#11=42%
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Endpoint: VRI=Ventriculostomy related infection
Quality: VL=very low, L=low, M=moderate, H=high, VH=very high
CS-P
VRI
Evidentiary table 7
PICO Question: In adult patients with an EVD, does the risk of infection increase with duration of placement?
Reference
[ #]
#31Arabi
2005
#102
Korinek
2005
Patient Underlying Study Endpoint Findings
number Clinical
Design
Condition(s)
1.2 OR
84
4,7,8
CS-P
VRI
Quality Comments
VL
total, OR
(< 7 days)
2.82; OR
>7 days
1.18
175
1,2,3,4,8
CS-P,
CS-R
VRI
EVD >5d
vs
EVD>10d
not a risk
factor for
infection.
Days
VL
VRI
Definition:
Primary:
(+)culture of
known
pathogen,
secondary:
"contaminant"
with CSF or
clinical
meningitis
OR
CLINICAL
only (CSF
and pt
changes)
VRI
Definition:
Fever >38.5C,
(+) a positive
CSF culture
associated
with CSF
#103
Scheithauer
2009
1333
NA
CS-P
VRI
#104
Arif 2012
104
1,2,3
CS-R
VRI
mean+/SD VRI
12.5+/11, noVRI
9.4+/-7
No
L
significant
difference
in VRI in
EVDs in
less than
or more
than 9
days
pleocytosis
(>15 cells)
CSF:plasma
glucose ratio
of less than
0.5
VRI
Definition:
CDC
definition +
CSF cellular
and chemical
changes +
Clinical
changes
EVD> 8
days
16/19
VRI;
EVD<4
days 3/19
VRI
VRI
Definition:
(+) CSF
culture. In the
absence of
positive
culture,
infection was
defined as
greater than
50% PMN on
CSF count
with a
minimum of
50 cells or
VL
#105
Bota 2005
638
1,2,3,4,6,7
CS-P
VRI
#106
Camacho
2011
119
1,2,4,5
CS-P
VRI
#107
Chi 2010
197
1,2,3,4,5,8
CS-R
VRI
#108
Lyke 2001
157
1,4,5,7,8
CS-P
VRI
No infxn
L
until d#3,
linear
increase
d3-10,
sharp
cutoff of
infections
after
D#10
Catheter
VL
days noVRI 7 (133); VRI:
10.3(426)
Mean
VL
daysVRI:20+/7.8d, noVRI
14.7+/10d
VRI: 8.5d
(2-23),
no-VRI:
5.1d (1-
VL
CSF glucose
less than
15mg/100ml
VRI
Definition:
Per Lozier, et
al. [91]
VRI
Definition:
CDC, Horan,
et al. [92]
VRI
Definition:
Clinical
suspicion +
culture of a
pathogen
from CSF
(except d#1)
VRI
Definition:
Recognized
pathogen OR
23). 73%
of VAI
developed
after 6d
skin flora and
1 or more
criteria:(+)
gram stain,
low glucose,
high protein,
CSF
PMN>10,
excluded
those with
only (+) CSF
parameters
and (-) culture
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Endpoint: VRI=Ventriculostomy related infection
Quality: VL=very low, L=low, M=moderate, H=high, VH=very high
Evidentiary table 8
PICO Question: In adult patients, do prophylactic systemic antimicrobials reduce the incidence of VRI? Should a periprocedural or
duration regimen be used?
Reference
[ #]
Patient
number
Arabi 2005 [31] 84 (58 for
comparison)
Underlying
Clinical
Condition(s)
4,7,8
Study
Design
Endpoint
Findings
Quality
Comments
CS-P
VRI
Periprocedural:
Cefazolin OR
Ceftriaxone OR
Cefuroxime.
VL
VRI Definition:
Primary: (+)culture of
known pathogen,
secondary:
"contaminant" with CSF
or clinical meningitis
OR CLINICAL only
(CSF and pt changes)
VL
VRI Definition: CDC,
Horan, et al. [92]
Antibiotic use
associated with
lower VRI rate;
infection
developed in 7 of
58 (12%) with
antibiotics and in
12 of 41 (29%)
when no
antibiotics used (P
= .03).
#106
Camacho 2011
119
1,2,4,5
CS-P
VRI
Periprocedural:
1st or 2nd or 3rd or 4th
generation
cephalosporin. Use
of antibiotics
increased risk of
VRI (nonsignificantly p=.22)
with an OR of 1.8
#109
Dellit 2014
721
4
CS-R
C. difficile
colitis
#101
Mayhall 1984
172
2,3,4,5
CS-P
VRI
#102
Alleyne 2000 [
308
4,5,8
CS-P
VRI
Duration vs
Periprocedural:
Cefazolin
No significant
difference in VRI
(p=.29). Significant
drop in C. difficile
when changed to
periprocedural
(5.4% to 2.4%,
p=.04)
Periprocedural:
Nafcillin 4 doses.
No significant
difference between
antibiotic and no
antibiotic group
(p=.09)
VL
VRI definition: (+) CSF
culture
VL
VRI definition: (+)
culture 24h after
insertion
Duration vs
Periprocedural.
Cefuroxime. No
significant
VL
VRI definition: (+) CSF
culture
difference in VRI
rate between
duration (3.9%) and
periprocedural
(3.8%)
#111
Poon 1998
228
4,5,8
R
VRI
Duration (D) vs
Periprocedural (P)
Amp/Sul
+Aztreonam (D) vs
Amp/Sul (P)
Significant
reduction in VRI in
D cohort (p=.01),
but more resistant
organisms and
higher mortality in
D cohort.
L
#112
Saini 2012
42
1,2,3,4,5,8
R
VRI
#113
Wong 2006
255
4,5,8
R
VRI
Duration (D) vs
VL
Periprocedural (P).
Ceftazadime.
No significant
difference in VRI
between D (6.67%)
and P(7.4%)
Duration: Two
VL
antibiotic regimen.
Amp/Sul
+aztreonam vs
Cefepime. Cefepime
VRI definition:
Not stated
VRI definition:
(+) CSF or EVD tip
cultures. CSF drawn on
D# 0,1,3,5
VRI Definition: At least
one of the following
criteria must have been
met: (1)(+) Culture
and/or (2) fever (>38
cohort with 6%
VRI,
Amp/Sul+aztreonam
with 12% VRI
#114
Blomstedt 1985
52
NA
R
VRI
Duration: TMPVL
SMX vs. placebo.
No difference in
VRI (1 from each
group)
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Endpoint: VRI=Ventriculostomy related infection
Trimethoprim/sulfamethoxazole= (TMP/SMX)
Ampicillin/Sulbactam=Amp/Sul
Quality: VL=very low, L=low, M=moderate, H=high, VH=very high
°C) and any of the
following: (a) Increased
white cells (>50%
PMN), increased
protein, and/or
decreased glucose (<15
g/dL) or (+) CSF gram
stain. All CSF infections
within 3 months after
EVD insertion
considered to be related.
VRI Definition: NA
Evidentiary table #9
PICO Question: In adult patients with an EVD, does the use of antimicrobial-impregnated catheters reduce the incidence of VRI?
Reference
[ #]
Patient
number
#115
Zabramski
2003
306
#116
Wong
2010
184
Underlying
Clinical
Condition(s)
2, 4,8
9, 4
Study
Design
Endpoint
Findings
Quality
Comments
R
VRI
ABX 1.3%
vs. S 9.4%
(p=0.002)
H
MLR for
prediction
of VRI
ER
placement
(OR 7.3;
p=0.035),
Presence
of other
infection
(OR
5.1;p=0.04
7), ABX
catheter
(OR 0.14,
p=0.014)
ABX 51%
vs. S 57%
(OR 1.3;
95% CI
0.7-2.2)
VRI
defined as
positive
CSF
culture
(i.e.
organism
grew on
two
different
media)
M
VRI
defined as
a positive
CSF
culture
and CSF
white
blood cell
count >
10/mm3
CSF
R
VRI
protein >
0.8 g/l,
and CSF
serum
glucose
ratio of <
0.4.
Open label
trial.
#117
Pople
2012
484
1, 10, 11
R
Proven
VRI
ABX 2.3
vs. S 2.8%
(p=1.0)
Suspected
VRI
ABX 17.6%
vs. 20.4%
(p=0.504)
Duration
of time to
suspected
infection
ABX
8.8±6.1
days vs S
4.6±4.2
days
(p=0.002)
M
Possible
type 2
error
Open label
trial.
Proven
VRI was
defined as
positive
gram stain
and
positive
culture
grown in
agar.
Suspected
infection
was
defined as
culture
positive
but not
seen on
gram stain
or culture
#118
Harrop
2010
Period
1 = 327
EVD
8
POC
VRI
Period
2 = 281
EVD
Period 1
6.7% vs.
Period 3
1.0%
(p=0.005)
L
Period
3 = 195
EVD
#119
Muttaiyah
2010
120
patient
s and
986
CSF
8
POC
compar
ed to
historic
al
VRI
ABX 5%
vs. C 15%
(P=0.0627)
VL
negative
but
positive
gram stain
or CSF
leukocytos
is with a
white
blood
cell/red
blood cell
count of >
0.02
VRI
defined as
2 positive
CSF
cultures
and a
concurrent
increase in
the CSF
white
blood cell
count.
ABX
catheters
introduced
in period
3; baseline
= period 1
VRI
defined as
a positive
CSF
culture
sample
s
#120
McLaughli
n 2011
75
control
s
2
POC
VRI
9.3%
Time to
Infection
Median of
16 days
VL
and CSF
leukocytos
is > 5 x
106 / L,
CSF
leukocytos
is were
corrected
for
erythrocyt
es in the
CSF by
subtractin
g1
leukocyte
for every
1000
erythrocyt
es in the
CSF.
No
Compariso
n group.
VRI
defined as
organism
isolated
via culture
and fever,
headache,
nuchal
rigidity,
meningeal
signs,
irritability
AND
#121
Mikhaylov
2014
145
10, 1, 2, 9,
4, 5,
Retro
VRI
ABX 4%
vs. 10%
(p=0.193)
VL
#122
Keong
2012
278
1, 2, 4, 12
R
VRI
Silver
12.3% vs.
21.4%
(p=0.0427)
H
antimicrobi
al
treatment
AND any
of the
following:
positive
gram
stain,
increased
white
blood
cells,
elevated
proteins
and/or
increased
decreased
CSF
glucose,
organism
isolated
from blood
culture.
VRI
defined as
a positive
CSF
culture.
Possible
type 2
error
VRI was
defined as
organisms
seen on
microscop
#123
Lackner
2008
39
1,2,9, 5,
POC
compar
ed to
historic
al
control
s
VRI
Silver 0%
vs. S 25%
(p<0.05)
VL
#124
Fichtner
2010
164
1,2,4,8
Retro
VRI
Silver
18.9% vs.
S 33.7
(p=0.04)
L
#125
Lajcak
2013
403
patient
s with
529
EVD
61
1,2,4,5
Retro
VRI
Silver 6.1%
vs. S 13.8
(p=0.003)
VL
2
R
VRI
Silver 10%
vs. ABX
L
#126
Winkler
y or
isolated by
culture or
clinical
meningitis
requiring
treatment.
Possible
Type 1
error.
VRI
defined as
positive
culture.
VRI
defined as
positive
culture or
colonizatio
n of
catheter
tip with
microorga
nism or
raised
liquor cell
count >
than 4
cells/mcl.
VRI
defined as
positive
CSF
culture.
Confirmed
VRI
2010
#127
Lemcke
2012
18%
(p=0.71)
95
1,2,4,10
Retro
VRI
Silver 9.4%
vs. ABX
6.5% vs. S
15.6
defined as
leukocyte
count per
visual field
> 200 and
clinical
signs of
CSF
infection
present
and
microorga
nisms
identified
in the CSF
or catheter
tip.
Probable
VRI
defined as
leukocyte
count per
visual field
> 100
and/or one
or cmore
of the
confirmed
VRI items.
VL
Possible
type 2
error
VRI
defined as
the
identificati
(p>0.05)
on of
microorga
nisms in
the CSF.
Possible
type 2
error
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown 9=stroke 10=hydrocephalus
11=Edema 12=AVM 13=SDH
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial, POC = Prospective
Observational Cohort, Retro = retrospective
Endpoint: VRI=Ventriculostomy related infection, MLG=multivariate logistic regression
Findings: ABX=antibiotic impregnated catheter, S=Silicone catheter, C=Control
Quality: VL=very low, L=low, M=moderate, H=high, VH=very high
Evidentiary table 10
PICO Question: Are additional intra-ventricular antimicrobials effective for the treatment of VRI as compared to intravenous antimicrobials alone?
Reference
[ #]
Patient
number
Underlying
Clinical
Condition(s)
1, 4, 6 (
Staphylococcal
VRI)
Study Design
#133
Pfausler
2003
10
#134
Remes
2013
#129
Wilke
2013
Endpoint
R – Vent
only Vs IV
only
-CSF bacteriologic
clearance.
-CSF vancomycin
Levels
34
1,2,5,6,7
CS Vent+ IV
Vs IV only
48
1, 2,3,5, 7
CS-R
Vent+ IV Vs
IV only
-Time to CSF
bacteriologic clearance.
-Modified Rankin scale.
-Attributable death.
-Adverse effects.
-Time to CSF
bacteriologic clearance.
-Time to normalization
of CSF WBC count.
-Length of stay.
-Length of IV.
VRI=Ventriculostomy related infection
Quality: VL=very low, L=low, M=moderate, H=high, VH=very high
Interventions: Vent- Intraventricular antimicrobials, IV: intravenous antimicrobials
Findings
Higher CSF
vancomycin
level with
intraventricular
compared to
intravenous
with no
difference in
CSF bacterial
clearance
Earlier time to
CSF clearance
and clinical
outcome ( see
text for details)
All the
outcomes were
significantly
better with
vent+IV ( see
text for details)
Quality
Comments
VL
The study,
though an
RCT, was
underpowered
VL
Underpowered
VL
Retrospective
study with a
scope for bias
and
confounding
PICO
Question:
Are
additional intra-ventricular
antimicrobials effective for
the treatment of VRI as
compared to intravenous
antimicrobials alone?
Key: Underlying Clinical
Condition 1=ICH 2=SAH
3=IVH 4=TBI 5=tumor
6=infection 7=nontraumatic
8=unknown
Study Design: CS-R=Case
series cohort-retrospective,
CS-P=Case series cohortprospective, R=randomized
trial
Endpoint:
Evidentiary table 11
PICO Question: In adult patients requiring an EVD, does routine CSF sampling increase EVD-related infections as compared
to maintaining a closed system with sampling of CSF only when clinically indicated?
Ref
No.
Author/
Year
Patient
number
Study
Design
Endpoint
Findings
Quality
Comments
84
Underlying
Clinical
Condition(s)
1, 4, 5, 6
31
Arabi/
2005
CS-R
Frequency of CSF
sampling
Very
low
Single center, small number
of patients, retrospective
review
Stenager/
1986
85
1, 2, 3, 4, 5
CS-P
Very
low
Single center, small number
of patients, CSF sampling
included with other
manipulations
136
Kitchen/
2011
133
2
CS-R
Frequency of
manipulations was
monitored; included
CSF samples,
irrigation when
occluded, change of
EVD
Frequency of CSF
sampling; compared
control group with
sampling when
indicated vs. research
group is frequent
sampling
Found no difference in
VRI* – CSF daily
samples vs. CSF
samples when
indicated
Found no difference in
VRI associated with
number of catheter
manipulations
135
Frequency of VRI was
significantly lower in
research group with
sampling group
Very
low
137
Williams/
2011
382
2, 4
CS-P
Historical control
group – daily CSF
sampling vs. every 3rd
day CSF sampling
Very
low
138
Williamson/
2014
420
Not provided
CS-R
Monitored frequency
of CSF sampling
Switch to every 3rd day
sampling was
associated with a
significant decrease in
VRI (p = 0.02)
Univariate and
multivariable analysis
Single center, retrospective
review, control group very
high VRI rate of 52.1%;
comparison of the effect of
sampling frequency on VRI
in research group was
complicated by
implementation of an EVD
management bundle
Confounding influence was
use of AI-EVD* in 75% of
patients in prospective study
arm of every 3rd day CSF
sampling
Single center, frequency of
CSF sampling was monitored
Low
modeling found CSF
sampling was
associated with a
significantly increased
risk of VRI
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
VRI* = ventriculostomy associated infection, AI-EVD* = antibiotic-impregnated external ventricular drain catheter
and not specified
Evidentiary table 12
PICO Question: In adult patients requiring an EVD, do routine catheter changes decrease the incidence of VRI compared
to no catheter changes?
Ref
No.
First Author/
Year
Patient
number
Study
Design
Endpoint
Findings
Quality
Comments
84
Underlying
Clinical
Condition(s)
1, 4, 5, 6
31
Arabi/
2005
CS-R
Rate of VRI was
significantly higher in
patients with 2 or
more EVDs (p <
0.001)
Low
Single center, small
number of patients,
retrospective review
Mayhall/
1984
172
4
CS-P
VRI* rate – VRI rate
in patients with single
EVD placement vs the
rate in patients
requiring 2 or more
EVDs
VRI rate epidemiology study
performed to identify
risk factors for VRI
101
Very low
Single center, observational
study, recommendation
based on small number of
observations (only 19
positive culture cases).
135
Stenager/
1986
85
1, 2, 3, 4, 5
CS-P
VRI rate and catheter
duration
Risk of VRI increased
after 5 days,
recommended
changing EVD site if
monitoring required
for more than 5 days
VRI were equally
distributed from day 2
to 11; no new
infections after day 11
Very low
142
Holloway/
1996
584
4
CS-R
VRI rate and catheter
duration
Low
143
Lo/
199
1, 2, 4
CS-R
VRI rate
Patients that had
catheters replaced
prior to 5-days did not
have a lower infection
rate. Incidence of
infection declined
after 10 days in single
catheter group
Univariate and
Single center, small
number of patients, indirect
evidence based on analysis
of VRI and catheter
duration
Single center, retrospective
review,
Low
Single center, retrospective
2007
144
Park/
2004
595
1, 2, 3, 4, 5
CS-R
VRI rate and catheter
duration
145
Wong/
2002
103
4, 7, 8
R
VRI rate –
Group 1 – routine
change of EVD site
every 5 days vs.
Group 2 – no change
unless clinically
required
multivariate analysis
found a significantly
increased risk of
infection associated
with each EVD
insertion (p < 0.001)
Rate of infection
plateaued after 4 days
and was not affected
by catheter changes
No significant
difference in VRI rate
between two groups
(p = 0.50)
review
Low
Single center, retrospective
review, indirect evidence
Moderate
Limited to two centers,
small sample size, infection
rate was twice as frequent
in Group 1 (7.8%)
compared to Group 2
(3.8%) reflecting a possible
Type 2 error
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
VRI* = ventriculostomy associated infection
Evidentiary table 13
PICO Question: In adult patients requiring an EVD does gradual weaning decrease the incidence of hydrocephalus and need for VP
shunting as compared to immediate clamping?
Ref
No.
First Author/
Year
Patient
number
146
Klopfenstein/
2004
91
Underlying
Clinical
Condition(s)
2
Study
Design
Endpoint
Findings
Quality
Comments
R
Comparison of VP
shunting rates in a two
groups: Group 1 –
standard 4 day gradual
weaning protocol vs.
Group 2 – simple
clamping
No difference in VPshunting rates in the
two groups.
The gradual weaning
group spent a mean of
2.8 more days in the
ICU (p = 0.0002) and
2.4 more days in the
hospital (p = 0.0314)
Medium
Single center, small
number of patients, study
limited to aneurysmal SAH
patients.
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
Reference 130 and 142 are duplicates
Evidentiary table 14
PICO Question: In adult patients requiring an EVD, does the type of dressing reduce VRI?
Ref
No.
First Author/
Year
Patient
number
147
Bookland/
2014
332
149
Honda/
2010
911
Underlying
Clinical
Condition(s)
1, 2, 4, 5, 7,
8,
Study
Design
Endpoint
Findings
Quality
Comments
CS-R
Single center, retrospective
review
CS-R
VRI rates were
significantly decreased
in the treatment group
(3.54%) vs. the control
group (15.1%) p =
0.002
VRI rates were
decreased from 3.29
per 1,000 catheter
days in the control
group to 2.17 per
1,000 catheter days in
the treatment group
Low
1, 7, 8
VRI* rate in control
group – semi-occlusive
dressing EVD site vs.
treatment group dressing
of EVD wounds with
cyanoacrylate
VRI rate in control group
– semi-occlusive gauze
dressing changed only if
necessary vs. treatment
group – semi-occlusive
gauze dressing changed
every 48 hrs
Very low
Single center, retrospective
review, only a trend for
decreased VRI rate
demonstrated
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
VRI*=Ventriculostomy related infection
Evidentiary table 15
PICO Question: In adult patients, does routinely changing the tubing and collection devices decrease the incidence of
EVD-related infection?
Ref
No.
First Author/
Year
Patient
number
Study
Design
Endpoint
Findings
Quality
Comments
32
Underlying
Clinical
Condition(s)
8
150
Duncan/
2011
CS-R
Changing drainage
sets weekly was
associated with a
decreased risk of VRI
Very low
Single center, retrospective
review, very small number
of patients, published as a
peer reviewed meeting
abstract
Korinek/
2005
377
8
CS-R
Comparison of VRI*
rates in control group
– change of drainage
sets every 3-days vs.
changing drainage sets
once per week
VRI rates before and
after implementation
of a EVD care bundle
102
Very low
Single center, retrospective
review, indirect evidence
against any manipulation of
the EVD drainage system
American
Association
of
Neuroscience
Nurses
NA
NA
Expert
consensus
statement
During the study
period VRI rates were
significantly
associated only with
CSF leak and protocol
violations
Inappropriate CSF bag
sampling p = 0.0002
Inappropriate CSF tap
sampling p < 0.0001
EVD manipulation p <
0.0001
Recommends against
routinely changing
EVD components
152
Very low
Consensus statement
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
VRI*=Ventriculostomy related infection
Evidentiary table 16
PICO Question: In adult patients does introduction of an EVD management bundle reduce the risk of EVD related infections?
Ref
No.
First Author/
Year
Patient
number
140
Kubilay/
2013
2,928
EVD*
placements
(no. of
Underlying
Clinical
Condition(s)
8
Study
Design
Endpoint
Findings
Quality
Comments
CS-R
VRI* rate following
implementation of an
EVD management
bundle
VRI rate decrease
from 9.2% in the
control period to
0.46% following
bundle implementation
Low
Single center, retrospective
review.
Note: Bundle included an
AI-EVD* catheter
During the study
period VRI rates were
significantly
associated only with
CSF leak and protocol
violations
Inappropriate CSF bag
sampling p = 0.0002
Inappropriate CSF tap
sampling p < 0.0001
EVD manipulation p <
0.0001
VRI rate decreased
significantly when the
EVD management
bundle included an AIEVD (p ≤ 0.005)
VRI rates were
decreased from 3.29
per 1,000 catheter
days vs. 0.87 per 1,000
catheter days
(p = 0.066)
Very low
Single center, retrospective
review, indirect evidence
against any manipulation of
the EVD drainage system
Medium
Single center, retrospective
review. Study periods
without and with the use of
AI-EVD strengthen the
quality of the results
Single center, retrospective
review
patients not
provided)
102
Korinek/
2005
377
8
CS-R
VRI rates before and
after implementation of
a EVD care bundle
118
Harrop/
2010
1,634
8
CS-R
VRI rate following
implementation of an
EVD management
bundle
149
Honda/
2010
911
1, 7, 8
CS-R
VRI rate before and
after implementation of
an EVD management
bundle
Low
154
Bader/
1995
19
8
CS-R
VRI rate following
implementation of a
best practice EVD
bundle
Infection rate reduced
Very-low
from 55.5% (n=9) in
6-month interval
before vs. 0% (n=10)
after implementation
of bundle
155
Camacho/
178
1, 2, 4, 5
CS-R
VRI rate during a series Education
Low
2013
of four educational
interventions were
interventions as part of
useful in reducing
EVD management
theVRI rate. During
bundle
the study, EVD-related
infection rates
decreased from 9.5%
to 4.8% per patient,
from 8.8% to 4.4% per
procedure, and the
incidence density
dropped from 14.0 to
6.9 infections per 1000
catheters-day (p =
0.027).
156
Dasic/
95
8
CS-R
VRI rate before and
Infection rate reduced
Low
2006
after implementation of from 27% before vs.
an EVD management
12% after
bundle
implementation of
bundle (p < 0.05)
157
Flint/
262 EVD
1, 2, 3, 4, 5,
CS-R
VRI rate before and
Infection rate reduced
Low
placements 8
2013
after implementation of from 9.8% before vs.
(no. of
an EVD management
0.8% after
patients not
bundle
implementation of
provided)
bundle (p = 0.02)
Key: Underlying Clinical Condition 1=ICH 2=SAH 3=IVH 4=TBI 5=tumor 6=infection 7=nontraumatic 8=unknown
Study Design: CS-R=Case series cohort-retrospective, CS-P=Case series cohort-prospective, R=randomized trial
EVD*=external ventricular drain, VRI*=Ventriculostomy related infection, AI-EVD*=antibiotic-impregnated EVD
Single center, retrospective
review, small number of
patients
Single center, retrospective
review.
Single center, retrospective
review
Single center, retrospective
review.
Note: Bundle included an
AI-EVD catheter