VP Shunt Infxn 1980s

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Acta Neur0chirurgica 59, 157--166 (1981)A C TA

N E U R O C H I R U R G I C A

9 by Springer-Verlag 1981

Division of Neurosurgery * and Department of Pediatrics ****,University of California at San Diego, California, and

Division of Neurosurgery ** and Department of Pediatrics ***,University of Kentucky Medical Center, Lexington, Kentucky

Th e M anagem ent o f Cerebrosp ina l F lu id Shunt In fec tions

A-Cflnical Experience

By

H . E . J a m e s * , J . W. W a l s h * * , H . D . W i l s o n * * * ,and J . D. Con nor ** **

S u m m a r y

Fifty patients with infected cerebrospinal fluid shunts were treated byone of three forms of treatment:

a) Twenty-two patients had shunt removal, systemic antibiotic treatment,and either external ventricular drainage or intermittent ventricular taps fordecompression and antibiotic administrat ion.

b) Seventeen patients had removal and immediate replacement of the shuntwith intrashunt and systemic antibiotics.

c) Eleven patients received intrashunt and systemic antibiotics without shuntremoval.

In the first group, antibiotics were given for a period of one week; in

the second and third groups, intravenous antibiotics were administered for aminimum period of three weeks, and intraventricular antibiotics twice dailyfor two weeks. In all patients ventricular CSF was obtained and cultured48 hours after cessation of antibiotic therapy, and cultures were repeated withinfour months after completion of therapy. Twenty-one of 22 patients in thefirst group, as well as 11 of 13 of the second group, were successfully treated.In the third group only four of the 11 patients responded to treatment.

Keywords: CSF shunt; infections; therapy.

I n t r o d u c t i o n

There a re th ree cur re n t ly -empl oyed methods o f t r ea tmen t fo rthe manag emen t o f ce rebrosp ina l f lu id (CSF) shun t in fec tions . Al le m p l o y a c o m b i n a t i o n o f i n t r a v e n o u s a n d i n t r a v e n t r i c u l a r a n ti b i ot i c sbecause of the unpredic table concentra t ions of some ant ib iot ics inve nt ri cu la r f luid a2, aa. In one met hod the shu nt as sembly is not

11 Acta Neurochirurgica, Vol. 59, Fasc. 3--4


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1 58 H . E . J a m e set aL:

removed, and the ant ib io t ic i s adminis tered through the shunttwo weeks a long wi th sys temic an t ib io t i c t r ea tmen t fo r

w ee ks 14. ~8, a:,~ A Second me tho d con sists of r em ov al o f theshunt and immedia te inser t ion of a new shunt , fo l lowed by tvof in t rashunt and three weeks of in t ravenous ant ib io t ic t l18. 19 Som e a uthors ha ve repo rted that the sh unt assembi ~be removed, an external vent r icular device or a reservoi r in~and sys temic and in t ravent r icula~ ant ib io t ics adminis tered iper iod of time. W hen the infec t ion has been e liminated , a ne w s .m ay then be inserted ~, ~ 26.27

In a previous repor t the authors presented the i r exper ience in .prospect ive randomized s tudy of 30 chi ldren wi th infec ted CSIshunts and the previou sly-desc ribed three method s 1% Th is prospe ctiv,s tudy could not be cont inued as i t was fe l t by the authors of thes tudy tha t the h igh inc idence of fa i lures in one of the t rea tmenregimes made the cont inuat ion o f it s appl ica t ion unjus t if ied . A,cordingly, pa t ients who subsequent ly presented wi th infec ted shul~were no longer submit ted to the r andom iza t ion p rocess . H ere xrepor t our exper ience in the management of 50 pat ients wi th shu.infec t ions .

M a t e r i a l s a n d M e t h o d s

T h e p a t i e n t s w e r e t r e a t e d i n t h e p e r io d f r o m S e p t e m b e r 1 97 5 t o S e p t e m b e r1 98 0. I n f e c t i o n w a s d o c u m e n t e d b y i d e n t i f i c a t i o n o f b a c t e ri a l o rg a n i s m s o nc u l t u r e o f C S F o b t a i n e d f r o m t h e s h u n t. T h i r t y - n i n e p a t i e n t s a ls o h a d s i m u l t a n e o u sc u l tu r e s o f b l o o d a n d u r i n e as p a r t o f th e i r p r e l i m i n a r y e v a l u a t i o n . T h i r t y o ft h e 50 p a t i e n t s f o r m e d p a r t o f t h e p r e v i o u s l y - r e p o r t e d s t u d y, a n d t h e m e t h oo f s e l e ct i o n o f t h e t h e r a p e u t i c m o d a l i t y i n e a c h p a t i e n t is d e s c r ib e d e l s e w h e r e 1,I n t h e r e m a i n i n g 2 0 p a t i e n t s t h e p a r e n t s o r g u a r d i a n s w e r e t o l d t h e o b j e c t i v e s

a d v a n t a g e s , d i s a d v a n t a g e s , r i s k s , a n d c o m p l i c a t i o n s o f a l l t h r e e m o d e s o s t h e r aa n d i n f o r m e d c o n s e n t fo r t r e a t m e n t w a s o b t a i n e d i n a l l c ase s.

A f t e r a p p r o p r i a t e c u l t u r e s w e r e o b t a i n e d , i n t r a v e n o u s a n t i b i o t i c t h e r a mw a s s t a r t e d p e n d i n g i d e n t i f i c a t i o n a n d a n t i b i o t i c s u s c e p t i b i l i t y o f t h e o rg a~ :,.s roW h e n t h e s e r e s u l t s w e r e a v a i l a b l e , t h e m o s t a p p r o p r i a t e a n t i b i o t i c w a s i n s t i ta n d d e f i n i t i v e t h e r a p y w a s b e g u n . I n 2 2 p a t ie n t s t h e s h u n t w a s r e m o v e d ,e x t e r n a l v e n t r i c u l a r d r a i n a g e ( E V D ) w a s i n s t i t u t e d , w i t h t w i c e d a i l y a n t i b kd o se s a d m i n i s t e r e d t h r o u g h t h e E V D ( s e ve n p a t i e n t s) . I n a n o t h e r 1 5 p a t in o E V D w a s p l a c ed , b u t i n t e r m i t t e n t o n ce d a i l y v e n t r i c u l a r p u n c t u r e s t h rt h e a n t e r i o r f o n t a n e l l e w e r e p e r f o r m e d f o r d e c o m p r e s s io n a n d a n t i b i o t i c a d m i n i :t i o n . I n e a c h ca s e a t o t a l o f s ev e n d a y s o f i n t r a v e n t r i c u l a r a n d i n t ra ~a n t i b i o t i c t h e r a p y w a s a d m i n i s t e r e d . F o l l o w i n g o n e o r t w o d a y s o f i n t r a va n t i b i o t i c t h e r a p y 1 7 p a t i e n t s u n d e r w e n t s h u n t r e m o v a l , w i t h i n s e r t i o n o f as h u n t a t t h e sa m e p r o c e d u r e . T h e r e m a i n i n g 11 p a t i e n t s d i d n o t h a v e .s h u n t s r e m o v e d . I n b o t h o f th e s e g ro u p s a n t i b i o t i c s w e r e g i v e n t w i c e &t h r o u g h t h e s h u n t r e s e r v o i r f o r a m i n i m u m p e r i o d o f t w o w e e k s, a n d b y t .i n t r a v e n o u s r o u t e f o r t h r e e w e e k s. D o s a g e s f o r i n t r a v e n t r i c u l a r a n d i n t r a v e n o u sa n t i b i o ti c s a re l i s te d i n Ta b l e 1. T h e c o n c e n t r a t i o n o f a n t i b i o t ic s in v e n t r i c u l a r


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Th erap y for Shunt Infections 159

;,d wa s measured a t freq uen t intervals, an d the dosage of medication was,~sted to achieve op tim al therapeutic concentrations. The antibiotic deterrnina-

i i~were made by the method of Simonet a l . 29, or of Braudeet al . 2.": ~ v y- ei gh t hours following completion o f therapy all patients had ventricular.-r~rations fo r cultures, as well as blo od an d urine cu ltures. A second CS F.,~s obtained from all patients within four months after the terminationoy. An infection was said to be cured when both these CSF cultures

,~ativ e. The follow -up t ime range d from one m onth to 58 months,: :~"mean of 15.3 __ 12 months.

~'~" Tab le 1.A n t i b i o t i c s a n d D o s a g e

[~ Intrave ntricular Intraveno us

5, Cep halothin 1-3.5 mg /kg dose" M ethicillin 1-2 m g/kg dose

Nafci l l in 1-4 mg/kg dosed~mp icillin 1-2 m g/kg dose~e nta m yc in 0 .5-2 .0 mg/kg dose.:~efazolin 1-2 m g/kg dose

9 ?enicillin 1,000 units dose

Cephalothin 150 mg /kg/dayM ethicillin 200 m g/k g/d ayOxacil lin 200 m g/kg /dayAm picillin 100-200 m g/k g/d ayCarbenicillin 400-600 m g/k g/d ayChloramphenicol 100 mg /kg/dayGentamycin 5-7 .5 mg /kg/dayKanam ycin 15 mg/kg /dayNafci l l in 150 m g/kg/dayTobramycin 5 mg/kg /dayAmikacin 15 m g/kg /dayRifampin 15 m g/kg/dayPenicillin 250,000 un its/kg /day

~> R e s u l t s

: ' T h e r e w e r e 5 0 p a t i e n t s i n t h e s t u d y, w i t h a g es r a n g i n g f r o m

~" 2 m o n t h s t o 9 y e a r s ; t h e r e w e r e 2 9 m a l e s a n d 2 1 f e m a l e s . E i g h t p a -u e n t s h a d s p i n a b if i d a , w h i c h h a d b e e n r e p a i r e d a t b i r t h . Ta b l e 2

~ s u m m a r i z e s t h e a e t io l o g y o f th e h y d r o c e p h a l u s . T h e r e w e r e 3 92 v n t r i c u l o - p e r i t o n e a l s h u n t s ; e i g h t p a t i e n t s h a d m o r e t h a n o n e i n t r a -

:! {: an ia l c a t h e t e r . T h e t y p e a n d l o c a t i o n o f t h e s h u n t s y s t e m isi p r e s e n t e d i n Ta b l e 3.

F o r t y - f i v e p a t i e n t s h a d s in g le o r g a n i s m i n fe c ti o n s , a n d a s i n o t h e r: : ~ m d i e s s, s la. x7, 24, 25 t h e m a j o r i t y w e r e d u e t o s t a p h y l o c o c c u s

~ q ~ ab le 4 ). F i v e p a t ie n t s h a d m o r e t h a n o n e i n f e c t i n g o r g a n i s m: ~ 'able 5) .

::> : Tw e n t y - o n e o f t h e 22 p a t ie n t s w h o h a d t h e ir s h u n t s r e m o v e d a n d~'~::ad e i th e r E V D o r i n t e r m i t t e n t v e n t r i c u l a r p u n c t u r e s w e r e c u r e d .

s i n t h e g r o u p w i t h s h u n t r e m o v a l a n d im m e d i a t e re p l a c e m e n t th e re~ i w e r e 1 5 c u re s a n d t w o f a il u re s . F i n a l l y, i n t h e g r o u p i n w h i c h t h e

s h u n t w a s n o t r e m o v e d t h e r e w e r e 4 su c ce s sf u l re s ul ts f r o m t h e

11 "


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160 H . E . James et al.:

Table 2 . Aetiology of H ydrocephalus

Communicating

a ) Seconda ry to i n t r ac ran ia l haemor rhage, pos t -men ing i t i s , o r t r aum a 13b) Id iopa th i c 5Aqu eductaI stenosis 14Arachnoid or epe ndy ma l cyst 3Dand y-Walker ma l fo rmat ion 4Chiari malformation( sp ina b i f ida wi th out aque ducta l s tenosis ) 6Obstructive due to neoplasm 4Obstructive, postinfectious 1

5Oo t a l

Table 3 . Types of Shunt Systems

Shun t l oca t ion :Ven t r i cu lo -pe r i tonea l 39

Ven t r i cu lo - jugu la r 2Two in t r ac ran ia l ca the t e r s - -pe r i tonea l shun t 8Lurnbope r i tonea l shun t 1

To ta l 50

Table 4 . Bacteriology of Infected Shunts

No. o f pa t i en t s

Single organism infec t io n: 45M ul t ip l e o rgan i sm in fec t ion : 5

Organisms identified in singlebacterial type infections

Staphylococcus epiderm idis : 31Staphylococcus aureus : 5M icrococcus : 1Pseudomonas ae rug inosa : 1Escherichia co li: 1H a e m o p h i l u s i n f lu e n z a e : 2Co ryne bac ter ium species: IStreptococcu s : 2Pro pion eba cter ium species : 1


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Th erap y for Shunt Infec t ions 161

11 pa t ien ts t rea te d (Table 6) . Th ree dea ths occu r red , tw o of thesei n t h e g r o u p w i t h o u t s h u n t r e m o v a l ; o n e p a t i e n t d e v e l o p e d a m o r evi ru len t and an t ib io t ic - res i s ten t super infec t ion (E . co l i and Pseudo-m o n a s ) , a n d a n o t h e r p a t i e n t f i n a l l y u n d e r w e n t a v e r y p r o l o n g e dE V D t h e r a p y c o u rs e, d y i n g w h e n t h e E V D a c c i d e n t ly b e c a m e d is -

Table 5 . Multiple Organism Shunt Infection

Pa t i en t number Organ i sm

# 7 Streptococcus p . , Pseudomon as aeruginosa,Staphylococcus aureus, unide nt i f ied gram negat ive rodStaphylococcus epidermidis , Coryn ebacter ium speciesStaphylococcus aureus , C oryneb acter ium speciesE. coli , Kleb siel la p. , S taphy lococcu s aureusE. coli , Proteus vulgaris

# 1 0# 1 1# 1 7# 2 3

Table 6 . Therapy and Results in CSF Infected Shunts

N um be r of Successful Unsuccessfulpat ients t r ia ls t r ia ls M orta l i ty

W ith rem oval of shunt * 22 21 1 1W i t h re m o v a land imm edia te replacem ent 17 15 2 0W ithout rem oval of shunt 11 4 7 2

* Includes one pat ient w ho received in t ravenous ant ib io t ics only ( lumbo -per i ton eal shunt).

connec ted . The th i rd p a t i en t w ho d i ed be longed to t he fi r st t rea t -ment group; he cons is ten t ly grew S . ep idermidis dur ing h is in te r-m i t t e n t v e n t r i c u l a r p u n c t u r e s d u r i n g t h e r a p y a f t e r t h e s h u n t w a sr e m o v e d . H e w a s a p r e m a t u r e ch il d w i t h i n t r a c r a n i a l h a e m o r r h a g eand an in t r ace reb ra l i n f ec t ed hae m a tom a tha t f a i led to become s te r il ew i t h o u r t r e a t m e n t .

The shun t a s sembly in e igh t pa t i en ts con ta ined m ore than onein t r ac ran ia l t ube connec ted to a s ing le pe r i t onea l ca the te r. Tw o o fthese pa t i en t s were i n t he EVD group , t h ree were in t he g roup wi thi m m e d i a t e s h u n t r e p l a c e m e n t , a n d t h r e e w e r e i n t h e g r o u p w i t h o u tshun t r emova l .


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162 H. E. James e t a i . :

In the group that had their shunts removed without immediatereplacement, shunt obstruction was noted in one patient on admission.Shunt obstruction also occurred in two patients in the group withimmediate shunt replacement.

D i s c u s s i o n

Infections continue to be one of the most frequent and seriouscomplications of CSF shunts. The incidence has been reported tobe as high as 27 26, and 31 per cent 20 in two large series. It wasini tially described in ventriculo-vascular shunts 4 .*5, but subsequentlymany reports have discussed and extended the disease to ventriculo-peritoneal and other shunts 5, 14, 15, 18, 2a 26, 2s

The approach to the management of infected CSF shunts hasvaried. Treatment with high dose intravenous antibiotics aloneSS,intravenous antibiotics with intrashunt antibiotics without shuntremoval 14, is, as, and removal and replacement of the shunt in thesame operation followed by intrashunt and intravenous anti-biotics 16, 19 have been advocated. Others have stated that a success-

ful outcome can only be seen when the infected assembly is re-moved a-5, is, 15, s6, s7The primary concept in present-day shunt therapy is that the

treatment of ventriculities generally requires that the antibiotic beadministered into a ventricle, since the ventricular penetration ofmany systematically administered antibiotics in infections of thisnature is erratic. Intravenous therapy alone for shunt infection w i l lseldom eradicate the disease sv. Thus the antibiotic is administeredby ventricular puncture in the newborn or i nf an t 1, 11. 21 30, or by

EVD 15. s3. 24, aa, or by implanted CSF reservoirs 11, 27, or directlyinto the shunt system is 1.9 as, 83 in older children.

Reasons for not removing the shunt are concern for shuntdependency and, in older children with functionally closed sutures,sudden deterioration due to rapid intracranial hypertension. Thismay occur in those situations in which the hydrocephalus is felt tohave "arrested", and prompt deterioration has occurred after shuntdysfunction. Also, the concern for the preservation of the venouschannel in the CSF-vascular shunts has led some authors to replace

the shunt immediately upon removing the infected one in the samelocation, thus not sacrificing permanently the pathway for theshunt 26, 19

Increased intracranial pressure should not occur when the shuntis removed, if EVD is instituted. This also has the advantage ofoffering a route for the administration of the intraventricular anti-


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Therapy for Shu nt Infections 163

b io ti cs . The haza rds o f d i sconnec t ing the sys t em by the unco ope ra t ivechi ld and sudden loss of CSF, as wel l as super infec t ion , a re po ten t ia lcompl ica t ions .

F lu id , e l ec tro ly t e , and p ro t e in r ep l acem en t m ay be needed fo r ach i ld on long - te rm EV D due to CS F loss. These r isks a re m in im izedin the ha nd s o f trai n ed nu rsin g pe rso nn el 6, 9, 15 28, 81. A n alt er na tiv ei s t he p l acemen t o f r e se rvo i r s t ha t wou ld have sk in cove r ing ye t a r eaccess ib le fo r C SF decompres s ion and an t ib io t ic adm in i s tr a t ion . H ow -ever, a t t imes th is is no t suff ic ien t for d ecom press ion in shunt -dep end en t chi ld ren . The re m ay a l so be d i f f i cu l ty i n e r ad ica t ing theinfec t ion because of the presence of the reservoi r sys tem. Th ere is a lsothe r i sk o f no socom ia l in fec tions 11

Argumen t s i n f avour o f shun t r emova l c i t e t he p r inc ip l e o fco lon iza t ion wi th in a fo re ign bod y ( shunt ) and ev idence tha t i n f ec -t ion wi l l no t c lear un less and unt i l the fore ign body i s removed.The re i s l i t t l e doub t t ha t t r ea tmen t when the shun t i s r emoved i so f t en m ore p ro m pt i n e r ad ica t ing the i n fec tion , as dem ons t r a t ed ina prev ious ran do m ized p rospec t ive s tud y 10. In i t se l f th is is im po r tan tbecause i t ha s been no ted by o the r s t ha t t he l ack o f an ea r ly and

effec t ive reso lu t ion of a sh unt in fec t ion is assoc ia ted wi th a h igherm or ta l i ty ra te 26, ~s, a f ind ing o f s ignif icance in olde r an d deb i l i ta tedpa t ien ts 6, 2~. In the pres en t s tud y tw o of th e e leven pa t ien ts w hod id no t have r emova l o f t he i r i n f ec t eds shun t d i ed , and they cons t i -tu te d tw o o f the th ree dea ths in th is se ries. O ne ch i ld d ied f romuncon t ro l lab l e sys t emic in fec t ion desp i te subsequen t shun t r em ova land in s t i t u t i on o f EVD; the o the r ch i ld d i ed a f t e r shun t r emova l anda p ro longed EVD cour se , w i th compl i ca t ions r e su l t i ng f rom d i s -connec t ion o f t he sys tem.

There i s s ign i f ican t var iab i l i ty in the an t ib io t ic concent ra t ion inthe in t r aven t r i cu l a r CSF, no t on ly f rom pa t i en t t o pa t i en t bu t a l soin the same pa t i en t d u r ing the r ap y ~ . Because o f t h is we r eco m m endsampl ing an t ib io t i c concen t r a t ion in t he ven t r i cu l a r f l u id du r ingthe rapy, t hus ad jus t ing the dose above the o rgan i sm ' s min ima l i n -h i b i t o ry c o n c e n t ra t i o n ( M I C ) . U n f o r t u n a t e l y, e v e n w i t h a d e q u a t econcent ra t ions of an t ib io t ics in the CSF, there i s no guaran tee ofreso lu t ion of the in fec t ion . Thus , in o ur prev ious re po r t 10 w e notedve ry h igh a n t ib io t ic con cent ra t ions (8 .8 to 128 pg/ml) , w el l abovethe bac t e r i a l MIC , i n fo u r o f f i ve s taphy lococcus shun t i n fect ionst r ea t ed wi thou t shun t r emova l , w i thou t r e so lu t ion o f t he i n fec t ion .Conve r se ly, one pa t i en t t r ea t ed wi th t he s ame t echn ique had lowant ib io t ic CSF concent ra t ions (0 .375-1 .0 pg /ml) , and in th i s par t ic -u la r case the s taphy lococcu s in fec t ion was cure d 1% These d i sc rep-anc ie s may be r e l a t ed to t he v i ru l ence o f t he o rgan i sm, t he ab i l i t y o f


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1 64 H . E . J a m e set el.:

the ant ib iot ic to reach in adequate levels the shunt sys tem in i t sen t i re ty as we l l a s the CSF pa thways ; many of these paramete rs a re

no t eas i ly assessed in each ins tance . A no ther argum ent for m easur ingin t raven t r i cu la r CSF an t ib io t i c concen t ra t ions dur ing the rapy i s thedes i re no t to reach too h igh a l eve l tha t may then p roduce a tox ice ffec t on the cen t ra l ne rvous sys tem 7. Th is becom es par t i cu la r lyimp or t a n t when h igh leve ls o f an ti b io t ic s a re em p loyed . W e foundtha t in mos t c i rcumstances in in fancy and ch i ldhood a 1 -2 mg/kg dosein to the ven t r i c le th rough the shun t , EVD, o r d i rec t ven t r i cu la rpunc ture , gave adequa te CS F leve ls (Tab le 1 ). M ore recen t ly,M cLaur in 14 and W ald and M cLaur in a~ have recom m ended h igherdoses , e spec ia l ly when the rapy i s be ing per fo rmed wi thou t shun tremova l .

A c k n o w l e d g m e n t s

W e e x t en d o u r a p p r e c i a t i o n t o K a t h i e L . S h e p h e r d f o r h e r v e r y p a t ie n ts e c r e t a r ia l w o r k .

R e f e r e n c e s

1 . B lev ins , J . , E r~cksson , C . D . , Ru iz -Pa l ac ios , G . , I n t r a ve n t r i cu l a r an d sy s t emicg e n t a m i c i n t h e r a p y f o r v e n t r i c u l i t is i n c h i l d r e n . P r o c . o f t h e I n t e r s c i e n c eC o n f . o n A n t i m i c r o b i a l A g e n t s a n d C h e m o t h e r a p y ; C h i c a g o , Il l in o i s , 1 97 6.

2 . B r a u d e , A . I . , B a n n i s t e r , J . , Wr i g h t , N . , U s e o f t h e g r a d i e n t p l a t e f o r r o u t i n ec l i n i c a l d e t e r m i n a t i o n s o f b a c t e r i a l s e n s i t iv i t ie s to a n t i b i o t ic s . A n t i b i o t i c sA n n a l s ( 1 9 5 4 - 1 9 5 5 ) , 11 3 3 - - 11 4 0 .

3 . Bruce , A . M. , Lo rbe r, J . , Shedden , W . I . H . , Za cha ry, R . B . , Pe r s i s t en tb a c t e r a e m i a fo l l o w i n g v e n t r ic u l o - c a v a l s h u n t. O p e r a t io n s f o r h y d r o c e p h a l u si n i n f a n t s . D e v . M e d . C h i l d . N e u r o l . 5 ( 19 6 3 ), 4 6 1 - - 4 7 0 .

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12. Lorber, J . , Ka lhan, S . C. , Magref te , B. , Treatmen t of vent r icul i t i s wi thgentamicin and c loxaci l l in in infants wi th spina b i f ida . Arch. Dis . Chi ld .45

(1970), 178--185.13. Lu kh ard t , T. , B acteria l infections in v en tricu lo-a uric ula r shunt systems.

Dev. M ed . Ch i ld . Neuro l .22 (Suppl.) (1967), 105--109.14. McLaurin, R. L. , Infected cerebrospinaI f luid shunts. Surg. Neurol . 1 (1973),

191- -195 .15. Mori , K. , Raimondi , A. J . , An analys is of external vent r icular dra inage as

a treatment for infected shunts. Child 's Brain 1 (1975), 243--250.16. Nicholas, J . L. , Kamal, I . M., Eckstein, H. B. , Immediate shunt replacement

in the t rea tment of bacter ia l coloniza t ion of Hol ter va lves . Dev. Med. Chi ld .Neuro l . 12 (Suppl.) (1970), 110--113.

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20. Robinson, J . S . , Raim ondi , A. J . , Co mp l ica t ions of vent r iculo -per i tonea lshunt ing procedures for congeni ta l and secondary hydrocephalus in chi ldhood.Proc. Am. Ass. Neurol. Surg., St. Louis, Missouri, 1974.

21. Salmon, J . H. , Ven tr icul it i s com pl ica t ing meningi t i s. Am . J . D is . Chi ld .40(1972), 124--135.

22. Salmon, J . H. , A du l t hydro cepha lus : Evaluat ion of shunt thera py in 80 pat ients .J . Neurosurg .37 (1972), 423--428.

23. Sayers, M. P. , Shunt com plicat ions. Clin. Ne urosu rg.23 (1976), 393--400.24. Scarff , T. B. , Nelson, P. B. , Reigel , D. H. , External dra inage for vent r icular

infection fol lowing cerebrospinal f luid shunts. Child 's Brain 4 (1978),129--136.

25. Schimke, R. T. , Black, P. H., Mark, V. H., Swartz, M. N., IndolentStaphylo-coccus albus or aureus bacterernia a f t e r ven t r i cu loa t r ios tom y: Ro le o f fo re ign

body in i t s in i t ia t ion and prepara t ion . N. Engl . J . Med.26 4 (1961), 264--270.26. Schoenbaum, S. D., G ard ner , P. , Sh il l i to, J . , Infection s of cerebrosp inaI

f lu id shunts : Epidem iology, c l in ica l m anifes ta t ions and therap y. J . Infec t .Dis . 131 (1975), 543--552.

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28. Shurt leff , D. B. , Foltz, E. L. , Weeks, R. D., Loeser, J . , Therapy for Staphy-lococcus epidermidis : Infec t ions associa ted wi th cerebrospinal f lu id shunts .Peds . 53 (1974), 55--62.

29. Simon, H . J . , Yin, E. J . , M icrobio assay of a ntim icrob ial agents. A pp l.

Microbiol .19 (1973), 573--579.30. Simpson, P. B., W arren , G. C. , Smith, R. R. , Intra ve ntr icu lar cephalo thin

in ch i ldhood v entr icul i t is . Surg . Neu rol . 4 (1975) , 279--282 .31. Smith , R. W. , Alksne , J . F. , Infec t ions com pl ica t ing the use of external

ventr iculos tomy. J . Neurosurg .44 (1976), 567--570.32. W ald , S . L . , McLaur in , R. L., C erebrospinal f lu id ant ib io t ic levels dur ing

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166 H .E . Jamese t a l . : Therapy for Shunt Infec t ions

33. W ilson, H . D ., Bean, J . R. , James, H . E. , Pen dley, M. M ., Cerebrosp inaIf lu id ant ib io t ic concentra t ions in vent r icular shunt infec t ions . Chi ld ' s Bra in 4

(1978), 74--82.

A utho rs ' addresses: H. E. James, M .D. , and J . D. Co nnor, M.D., U nivers i tyof C al i forn ia Med ical Center, 225 Dickinson St ree t, San D iego, CA 92103, U.S.A. ,J . W. Walsh , M.D. , Ph.D. , and H. D. Wilson, M.D. , Univers i ty of KentuckyM edical Center, L exington, K Y 40503, U.S.A.

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VP Shunt Infxn 1980s