Pediatric hydrocephalus

systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis

Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force

Research output: Contribution to journalArticle

26 Citations (Scopus)

Abstract

OBJECT: The objective of this systematic review and meta-analysis was twofold: to answer the question "What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?" and to make treatment recommendations based on the available evidence.

METHODS: The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

RESULTS: Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).

RECOMMENDATION: The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.

STRENGTH OF RECOMMENDATION: Level II, moderate degree of clinical certainty.

Original languageEnglish (US)
Pages (from-to)44-52
Number of pages9
JournalJournal of neurosurgery. Pediatrics
Volume14
DOIs
StatePublished - Nov 1 2014

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Hydrocephalus
Meta-Analysis
Guidelines
Pediatrics
Anti-Bacterial Agents
Randomized Controlled Trials
Infection
Odds Ratio
Medical Subject Headings
Databases
National Library of Medicine (U.S.)
PubMed
MEDLINE
Cohort Studies
Retrospective Studies
Control Groups
Therapeutics

Keywords

  • AANS = American Association of Neurological Surgeons
  • antibiotics
  • cerebrospinal fluid
  • CNS = Congress of Neurological Surgeons
  • evidence-based guidelines
  • hydrocephalus
  • infection
  • intravenous
  • meta-analysis
  • pediatrics
  • periopcrativc
  • practice guidelines
  • preoperative
  • RCT = randomized controlled trial
  • RR = risk ratio
  • shunt
  • VP = ventriculoperitoneal

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Pediatric hydrocephalus : systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis. / Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force.

In: Journal of neurosurgery. Pediatrics, Vol. 14, 01.11.2014, p. 44-52.

Research output: Contribution to journalArticle

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abstract = "OBJECT: The objective of this systematic review and meta-analysis was twofold: to answer the question {"}What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?{"} and to make treatment recommendations based on the available evidence.METHODS: The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).RESULTS: Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9{\%} compared with 10.7{\%} in the control group. Using a random-effects model, the cumulative RR was 0.55 (95{\%} CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).RECOMMENDATION: The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.STRENGTH OF RECOMMENDATION: Level II, moderate degree of clinical certainty.",
keywords = "AANS = American Association of Neurological Surgeons, antibiotics, cerebrospinal fluid, CNS = Congress of Neurological Surgeons, evidence-based guidelines, hydrocephalus, infection, intravenous, meta-analysis, pediatrics, periopcrativc, practice guidelines, preoperative, RCT = randomized controlled trial, RR = risk ratio, shunt, VP = ventriculoperitoneal",
author = "{Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force} and Paul Klimo and {Van Poppel}, Mark and Thompson, {Clinton J.} and Lissa Baird and Duhaime, {Ann Christine} and Flannery, {Ann M arie}",
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AU - Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force

AU - Klimo, Paul

AU - Van Poppel, Mark

AU - Thompson, Clinton J.

AU - Baird, Lissa

AU - Duhaime, Ann Christine

AU - Flannery, Ann M arie

PY - 2014/11/1

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N2 - OBJECT: The objective of this systematic review and meta-analysis was twofold: to answer the question "What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?" and to make treatment recommendations based on the available evidence.METHODS: The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).RESULTS: Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).RECOMMENDATION: The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.STRENGTH OF RECOMMENDATION: Level II, moderate degree of clinical certainty.

AB - OBJECT: The objective of this systematic review and meta-analysis was twofold: to answer the question "What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?" and to make treatment recommendations based on the available evidence.METHODS: The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).RESULTS: Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).RECOMMENDATION: The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.STRENGTH OF RECOMMENDATION: Level II, moderate degree of clinical certainty.

KW - AANS = American Association of Neurological Surgeons

KW - antibiotics

KW - cerebrospinal fluid

KW - CNS = Congress of Neurological Surgeons

KW - evidence-based guidelines

KW - hydrocephalus

KW - infection

KW - intravenous

KW - meta-analysis

KW - pediatrics

KW - periopcrativc

KW - practice guidelines

KW - preoperative

KW - RCT = randomized controlled trial

KW - RR = risk ratio

KW - shunt

KW - VP = ventriculoperitoneal

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JO - Journal of neurosurgery. Pediatrics

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