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• Factors influencing EVD related infections: unanswered questions
  NITISH AGARWAL
  Published on: 2 March 2018

• Published on: 2 March 2018

  Factors influencing EVD related infections: unanswered questions

  • NITISH AGARWAL, Neurosurgery Resident AIIMS, New Delhi

  I read with great interest the paper by Jamjoom et al.[1] The authors have done commendable work in establishing a national external ventricular drain related infection (ERI) rate and elucidating the factors influencing it in the largest prospective multicentre study. However, some questions have been left unanswered in this respect.
  One of the contributing factors to a low ERI rate in the study could have been the fact that majority (98.6%) of EVDs were inserted in the operating theatre. In their single centre retrospective study of 84 patients, Arabi et al[2] found that placement outside operating rooms was associated with a trend towards higher ERIs. Clark et al[3], in their retrospective review of complications of intracranial pressure monitoring in 140 trauma patients, noted that the incidence of major infectious complications (eg. clinical ventriculitis, subdural empyema, brain abscesses) was higher in the groups in which the catheter was placed in the intensive care unit. A randomised control trial would better examine the importance of this finding.
  In this study by Jamjoom et al[1], the authors found no significant difference between infected and uninfected cases with regard to the length of tunnelling. However, recent evidence although weak, points towards a preventive benefit of long tunnel EVDs over short tunnel EVDs.[4,5] Hence, a discussion about the role of tunnelling length in ERIs is felt missing in the paper.
  Korinek et al, in their stud...

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  I read with great interest the paper by Jamjoom et al.[1] The authors have done commendable work in establishing a national external ventricular drain related infection (ERI) rate and elucidating the factors influencing it in the largest prospective multicentre study. However, some questions have been left unanswered in this respect.
  One of the contributing factors to a low ERI rate in the study could have been the fact that majority (98.6%) of EVDs were inserted in the operating theatre. In their single centre retrospective study of 84 patients, Arabi et al[2] found that placement outside operating rooms was associated with a trend towards higher ERIs. Clark et al[3], in their retrospective review of complications of intracranial pressure monitoring in 140 trauma patients, noted that the incidence of major infectious complications (eg. clinical ventriculitis, subdural empyema, brain abscesses) was higher in the groups in which the catheter was placed in the intensive care unit. A randomised control trial would better examine the importance of this finding.
  In this study by Jamjoom et al[1], the authors found no significant difference between infected and uninfected cases with regard to the length of tunnelling. However, recent evidence although weak, points towards a preventive benefit of long tunnel EVDs over short tunnel EVDs.[4,5] Hence, a discussion about the role of tunnelling length in ERIs is felt missing in the paper.
  Korinek et al, in their study to test the effect of a strict protocol of care on ERI, have postulated that frequent manipulation of EVD increases the risk of related infections.[6] Since the study by Jamjoom et al[1] was a prospective study, this strength could have been utilised in determining the role of frequent manipulation of EVD (eg. dressing, flushing the system, administering intrathecal drugs) for purposes other than CSF sampling.
  Lastly, an analysis of the role of perioperative systemic antibiotics as a preventive measure in ERI could have been done as the evidence is still controversial in this regard.[6]

  REFERENCES
  1 Jamjoom AAB, Joannides AJ, Poon MT-C, et al. Prospective, multicentre study of external ventricular drainage-related infections in the UK and Ireland. J Neurol Neurosurg Psychiatry 2018;89:120–6. doi:10.1136/jnnp-2017-316415
  2 Arabi Y, Memish ZA, Balkhy HH, et al. Ventriculostomy-associated infections: incidence and risk factors. Am J Infect Control 2005;33:137–43. doi:10.1016/j.ajic.2004.11.008
  3 Clark WC, Muhlbauer MS, Lowrey R, et al. Complications of intracranial pressure monitoring in trauma patients. Neurosurgery 1989;25:20-4.
  4 Omar MA, Mohd Haspani MS. The Risk Factors of External Ventricular Drainage-Related Infection at Hospital Kuala Lumpur: An Observational Study. Malays J Med Sci MJMS 2010;17:48–54.
  5 Rafiq MFA, Ahmed N, Ali S. Effect of tunnel length on infection rate in patients with external ventricular drain. J Ayub Med Coll Abbottabad JAMC 2011;23:106–7.
  6 Korinek A-M, Reina M, Boch AL, et al. Prevention of external ventricular drain--related ventriculitis. Acta Neurochir (Wien) 2005;147:39-45; discussion 45-46. doi:10.1007/s00701-004-0416-z

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  Conflict of Interest:
  None declared.

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