In Reply: The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement
We sincerely appreciate the kind words and time you spent providing a thoughtful discussion 1 of our manuscript 2 in the context of the existing literature on ventriculoperitoneal (VP) shunt infections. Indeed, the authors highlight the significantly increased attention that this topic has received, with a number of interesting new studies that have been published since we first completed our initial analysis. Several of these investigations revolve around incorporating intraventricular
... ventricular antibiotic use within existing protocols designed to combat infection. Raygor et al 3 published a robust investigation that included over 300 pediatric VP shunt patients who were treated over a 10-yr period. The authors reported a high degree of adherence to the initial study protocol as well as an array of disease processes and ages, with nearly 1 quarter of patients under 6 mo of age. Of note, the patients in their study received both intraventricular as well as topical vancomycin, building on prior work demonstrating a significant association between topical antibiotic use and decreased rates of cerebrospinal fluid infection. 4,5 The authors employed subgroup analysis to explore the role of prophylactic vancomycin and demonstrated that a combination of prophylactic intraventricular and topical antibiotics was significantly associated with a decreased rate of postoperative shunt infections (3.2% vs 7.2%, P = .04). These data, combined with previously published works 6-9 as well as our recent analysis, 2 reflect the need to further explore this question via a randomized, controlled trial. In North America, the significant majority of infections are secondary to grampositive organisms, with Staphylococcus epidermidis and Staphylococcus aureus being the most frequently described pathogens. 10 However, many patients around the world are experiencing increased rates of gram-negative infections. 11 As such, a clinical trial of prophylactic, intraventricular antibiotic administration consisting of vancomycin +/− gentamicin for gram-negative coverage may be particularly useful in determining whether these techniques, alone or in combination with other mechanisms of infection prevention, have the potential to reduce the incidence of shunt infections and subsequent revision surgery.