• John P Sheppard, Vera Ong, Carlito Lagman, Methma Udawatta, Courtney Duong, Thien Nguyen, Giyarpuram N Prashant, David S Plurad, Dennis Y Kim, and Isaac Yang.
• Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California.
• Neurosurgery. 2020 Jan 1; 86 (1): 19-29.

BackgroundExternal ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI.ObjectiveTo analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence.MethodsWe searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout.ResultsAcross 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis.ConclusionManagement with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.Copyright © 2018 by the Congress of Neurological Surgeons.

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