A systematic review of post-operative infections in pediatric ventriculoperitoneal shunt cases

Background. Hydrocephalus is a prevalent condition in children, affecting both developed and developing countries. Neurosurgical interventions such as ventriculoperitoneal shunts are common, but are associated with a high risk of complications, including infections, which can lead to additional issues and costs. This study aims to review the incidence of infection in pediatric patients before and after ventriculoperitoneal shunt placement, in order to address this issue. Methods. A standard process of analyzing scientific questions using the Population, Intervention, Control, and Outcome (PICO) method was used to develop a protocol for searching research articles in online databases such as PubMed, Cochrane, POPLINE, and Sciencedirect. The articles selected for inclusion in this study met the following criteria: 1) described interventional ventriculoperitoneal shunt placement in pediatrics, 2) focused on cases of ventriculoperitoneal shunt complications with a focus on infection, 3) were published within the last 10 years, and 4) were published in English-language journals with peer review standards. Results. Sixteen articles were identified for review. Seven of these articles mentioned surgical or mechanical interventions as a means of preventing infections, while six articles discussed medical treatment for infection prevention. Three articles described the microorganisms found in cerebrospinal fluid. Conclusion. Future studies should focus on the issues related to ventriculoperitoneal shunt complications and interventions related to immunological, neuroendocrine, and biophysical factors to prevent infections, as well as surgical management and medication administration.


INTRODUCTION
The number of hydrocephalus cases worldwide varies widely; the incidence of hydrocephalus in the United States is estimated to be between 0.5 and 4 per 1000 live births.The prevalence of hydrocepha lus ranges from 0.2 to 4 per 1000 live births.Hydro cephalus affects 0.2 out of every 1000 births in Japan.In Indonesia, approximately 2 cases of hydro cephalus are born every 1000 births.(AlTamimi, et al. 2014).
In pediatric patients with spina bifida, intraven tricular hemorrhage, possible hydrocephalus, or fluid space collections, Shunts are the preferred course of action, and their utilization can lower mortalityfrom this situation.Infection of the ven triculoperitoneal shunt is one of the most frequent conditions seen in pediatric surgery.If not treated right away, it can be fatal, especially in children.
However, there are numerous agents that can cause infection.Cerebrospinal fluid (CSF)related in fection is one of the most serious infections treated by neurosurgeons (Sahu 2009).According to studies, the prevalence of all shunt's ranges between 5 and 39% (Conen A, 2008;Kumar R, 2005), and 36% of parison and Outcome (PICO) formula.Cases of infec tious complications due to ventriculoperitoneal shunt treatment in children are an important con cern for neurosurgery clinicians.So, in this study, namely: How did the incidence of Ventriculoperito neal Shunt infection in pediatrics during the last 10 years occur?(P: pediatrics who met the criteria for infection after VPS, I: Ventriculo peritoneal Shunt (VPS), C: not infected, O: Safety or side effects) Anal ysis of the study questions was carried out using the Population, Intervention, Comparison and Outcome (PICO) formula.Cases of infectious complications due to ventriculoperitoneal shunt treatment in chil dren are an important concern for neurosurgery clinicians.So, in this study, namely: How did the in cidence of Ventriculoperitoneal Shunt infection in children develop hydrocephalus due to infectious etiology (Kumar, 2005).
As a result, pathologists and microbiologists must pay close attention.The author would like to conduct a literature review on the incidence of ven triculoperitoneal shunt infection in pediatrics over the last ten years.The aim of this research is to ex pand on the literature review and possibly find ap propriate therapies for the various infectious agents discussed below.

Research questions and search strategie
The analysis of the study questions this time was carried out using the Population, Intervention, Com A systematic review search was conducted with reference to the last 10 years of studies by identify ing studies describing cases of VPS infection in pedi atrics.Literature searches were performed via Pub Med, ScienceDirect, Cochrane, and POPLINE.The search strategy was carried out by using a combina tion of several keywords: Pediatrics, infection, ven triculoperitoneal, shunt.

Identification of relevant studies and data extraction
Articles were reviewed by all authors between August 2021 and September 2022.The search was restricted to publications published within the pre vious ten years, or from 2012 to 2022.Potential pa pers were initially evaluated based on their titles, and then they were evaluated based on their ab stracts.A thorough review of pertinent research was done while keeping the inclusion criteria in mind.From the articles they have reviewed, all au thors have taken extensive studies.

Quality appraisal
The NewcastleOttawa approach for cohort re search is required to conduct a critical evaluation in order to assess the validity and reliability of the cho sen articles.Following the tabulation of 16 papers, each study's selection, comparability, and outcome (Lo, ckl, 2014) were reviewed.As a quality assess ment, quality appraisal data is included into the re sults table.

Data analysis
Following the exclusion process, the selected re sults are entered into the RevMan software, which tabulates the data to produce the output of forest plot and funnel plot data.The main data were ex tracted and tabulated based on the required varia bles, namely data; demographics, number of sam ples, subject data, type of research, results of CSF culture, surgical intervention, and medical inter vention, and then quality assessment.

RESULT VPS Infection on Children
A total of 4318 reports were initially screened by title and abstract, 907 of which were taken for full text evaluation.A total of 108 reports were included in the systematic review.From 108 articles screened back to 51 articles are demographic descriptions of infection and CSF.Then as many as 16 research arti cles focused on VPS infection in pediatric cases.So that the 16 study articles were used as choices for indepth discussion.
The results of the demographic study of cases of ventriculoperitoneal shunt infection in pediatrics obtained as many as 16 articles with a retrospective and cohort research design.The data of retrospec tive research studies are sorted from 2012 to 2021.
Cases of shunt infection in 2012 with 3 results, namely 1) 16 cases from 203 samples, 2) 58 cases from 979 samples, and 3) In the 2013 study there were 71 cases from 1404 samples.
The 2014 study had two results: 1) 135 cases out of 500 samples, 2) 13 cases out of 90 samples.
Then the study in 2015 there were 28 cases of in fection from 384 samples.
The study in 2016 contained 24 cases from 246 samples.
The study in 2017 contained 305 cases of infec tion from 1357 samples.
The study in 2018 showed that there were 50 pos itive cases and in 2019 there were 30 out of 50 sam ples.
The 2019 study had 4 results, namely 1) 3 cases of infection from 78, 2) pre and post study 36 infected from 511, then 3) infected 93 out of 103 and 4) 4 cas es out of 14.
The 2020 study showed 19 cases of infection from 593 and in 2021 there were 68 cases of infection from 148 cases.

Microorganisms from cerebrospinal fluid (CSF) culture
A total of sixteen articles were found for review.Seven articles mention surgical or mechanical inter vention as infection prevention.A total of 6 articles mention advice on medical treatment to minimize infection.Three articles describe and mention mi croorganisms in cerebrospinal fluid. A

Surgical or mechanical intervention and medical treatment for shunt infection
Nine studies describe interventions in surgical techniques in a paper that suggests replacing a shunt device, namely: In cases of hydrocephalus, Thomale (2012) recommends using a differential pressure valve in conjunction with gravity.Hom melstad (2012) describes the use of perioperative protocols to significantly reduce infection rates in children.
Wang (2014) suggested emptying the subgaleal pouch before covering the scalp and avoiding pres sure on the wound or respiratory tract to reduce leakage.Wu (2015) suggested to completely remove foreign bodies in the body and stop antibiotic thera py.Erol (2017) suggests strengthening the more con cise handling strategy.Gaderer (2018) says to rinse neuroendoscopy and treat hydrocephalus in pediat ric cases.Sweeney (2019) describes removing or re moving pre and postprotocol shunts and using an External ventricular drain (EVD).
Test (2019) investigation focused on the response times of each bacterium that can infect the shunt de vice and be linked to leukocytes rather than how to handle it.According to Azzolini (2019), patients with complex circumstances need extra surgery to re place the shunt and have the procedure reevaluated to ensure the patient's safety.
A number of six studies explain the administra tion of drugs or antibiotics, namely James (2014) suggested using an Impregnated Shunt Antibiotic (AIS) catheter, Wu (2015) providing shortterm peri operative antibiotic prophylaxis to prevent Shunt According to the Raygor study, IVT and topical vancomycin administration should be added to the shunt surgery protocol.Sweeney (2019) combining removing the device and giving antibiotic therapy before and after was one of two articles that com bined the results of removing the total device and giving antibiotics.To prevent infection, Wu (2015) proposed removing the device and providing short term perioperative antibiotic prophylaxis.

DISCUSSION
Ventriculoperitoneal shunt treatment is a com mon procedure for managing hydrocephalus, but it is not without its risks, particularly the risk of infec tion.This discussion summarizes the findings of a systematic review on ventriculoperitoneal shunt (VPS) infections in pediatric cases.The review in cluded 108 reports, and the data was sorted from 2012 to 2021.The studies reported varying numbers of cases of shunt infection, with some studies re porting multiple results.The most common isolates were Staphylococcus epidermidis, Staphylococcus aureus, and gramnegative rods.The standard treat ment for shunt infections is to remove the infected hardware and begin intravenous antibiotic therapy.The review can inform the development of strate gies to prevent VPS infection in pediatric patients and improve patient outcomes.
Ventriculoperitoneal shunt treatment is com monly used in cases of hydrocephalus, but the risk of complications such as infection must also be con sidered.Despite the fact that this study is far from complete, the findings reveal infectious and nonin fectious cases of ventriculoperitoneal shunt servic es, particularly in children.In order for the tool that may represent a risk of infection during clinical work can receive more attention.In general, this analysis demonstrates that infections are frequently discovered in children who have received shunts (Figure 1).It is believed that a number of variables contributed to this ventriculoperitoneal shunt infec tion case.Equipment condition, installation prepa ration, management, and body condition are all contributing variables that result in this infection.
The paragraph presents the methodology and re sults of a systematic review of the literature on ven triculoperitoneal shunt (VPS) infection in pediatric cases.The review included 108 reports that were selected from an initial pool of 4318 reports based on title and abstract screening.Out of these 108 re ports, 51 were demographic descriptions of infec tion and cerebrospinal fluid, and 16 research arti cles focused specifically on VPS infection in pediatric cases.
The included studies had a retrospective and co hort research design, and the data were sorted from 2012 to 2021.The studies reported varying numbers of cases of shunt infection, with some studies re porting multiple results.For example, the 2012 stud ies reported 16 cases from 203 samples, 58 cases from 979 samples, and an unspecified number of cases from an unspecified number of samples.The 2017 study reported the highest number of cases with 305 cases of infection from 1357 samples, while the 2019 study reported four results, including three cases of infection from 78, 36 infected cases from 511 in a pre and poststudy, 93 infected out of 103 cases, and four cases out of 14.
The systematic review provides a comprehen sive overview of VPS infection in pediatric cases and highlights the frequency of infections in this popula tion.The findings of this review can inform the de velopment of strategies to prevent VPS infection in pediatric patients and improve patient outcomes (Majlesi A, et al. 2021) The systematic review on VPS infection in pedi atric cases provides a comprehensive overview of the frequency of infections in this population.The review highlights the importance of several varia bles that contribute to shunt infections, such as equipment condition, installation preparation, man agement, and body condition.The findings reveal that infections are frequently discovered in children who have received shunts.The most common caus ative organisms isolated from shuntinfected pa tients are Staphylococcus epidermidis, Staphylococcus aureus, and gramnegative rods.The review also reveals that complete removal of an infected shunt with placement of an EVD and administration of an tibiotics is far superior to immediate replacement with a new shunt or use of antibiotics alone.How ever, there are limitations to this study, such as the selection of studies with varying time periods and the use of pediatric age categories that are not yet defined.
Streptococcus aeurus, S. epidermis, and Gram negative microorganisms are prominent in this finding.These findings lend credence to the idea that concurrent infections in other parts of the body caused by the same gramnegative microorganisms may contribute to the higher incidence.The most common isolates were and gram negative (Paff M, et al 2018).
The findings of this systematic review on VPS in fection in pediatric cases demonstrate the impor tance of careful management and prevention strate gies in reducing the incidence of shunt infections.
The study highlights the need for greater attention to be paid to infection prevention during clinical work.The results suggest that infections are fre quently discovered in children who have received shunts, which indicates the importance of develop ing strategies to prevent VPS infection in pediatric patients and improve patient outcomes Fever and unconsciousness, stiffness in the neck, and headache are symptoms that will appear in the patient.This phenomenon occurs as a result of the characteristics of organism replication and virus growth on the surface of the shunt biofilm (McGirt 2003).In order of frequency, the most common causative organisms isolated from shuntinfected patients are Staph epidermidis, Staph aureus, and gramnegative rods (Mc Girt, 2003 andMcClinnton, 2001).
Staph epidermidis and Staph aureus are common skin flora, and skin contamination usually causes infection during shunt placement.As a result, infec tion from these organisms is usually present rela tively soon after shunt placement.McGirt et al. (2003) discovered that previous S. aureus shunt in fection significantly increased the likelihood that subsequent S. aureus shunt infections would pro duce S. aureus as the causative organism, but this trend was not observed with S. epidermidis infec tions.
The standard treatment for shunt infections is to remove the infected hardware and begin intrave nous antibiotic therapy.Treatment strategies for shunt VPS infection show that if the shunt is com pletely removed and antibiotic therapy is also ad ministered, 100% of patients recover.However, if the device is not removed and only antibiotics are used, the cure rate is only 9%.(Shurtlef 1974).Schreffler et al. (2002) also concluded that com plete removal of an infected shunt with placement of an EVD and administration of antibiotics is far superior to immediate replacement with a new shunt or use of antibiotics alone.Antibiotics given for VP shunt infections should be tested for culture sensitivity, so that the dose can be determined after wards.
The use of preoperative antibiotics (Ratilal, 2008), improving sterile technique (Rotim, 1997), and shortening the duration of the procedure are addi tional effective approaches to lower shunt infection rates.For instance, Rotim et al. (1997) followed a strict protocol for placing shunts, paying particular attention to skin preparation, prescribing perioper ative antibiotics, and limiting the length of the pro cedure to 40 minutes, and they discovered that their per patient rate of shunt infection decreased from 17.9% to 8% (Rotim, 1997).
The selection of studies with varying time peri ods and the use of pediatric age categories that are not yet defined are some of the limitations of this study.Therefore, a more thorough search and re search on pediatric ventriculoperitoneal infection with additional variables is required.
One of the limitations of this study is the selec tion of studies with varying time periods, which may impact the accuracy and generalizability of the findings.The use of pediatric age categories that are not yet defined is another limitation.Additionally, the study did not explore other factors that may con tribute to VPS infection in pediatric cases, such as socioeconomic status, race, or comorbidities.
Future research should focus on exploring addi tional variables that may contribute to VPS infection in pediatric cases, such as socioeconomic status, race, or comorbidities.Further research is also needed to determine the most effective strategies for preventing VPS infection in pediatric patients and improving patient outcomes.Additionally, fu ture studies should consider standardizing pediatric age categories to enhance the accuracy and general izability of the findings.Finally, more thorough search and research on pediatric ventriculoperito neal infection with additional variables is required to address the limitations of this study.

CONCLUSION
The potential for treating and preventing VP shunt infections in children is still needed and is crucial for additional research, even though the di versity of therapies in ventriculoperitoneal shunts must be adapted to the symptoms and diagnosis.The therapies employed in the past ten years to treat pediatric vp shunt infections and their microorgan ism population will be highlighted in this research.

FIGURE 1 .
FIGURE 1. Flowchart for the inclusion and exclusion criteria in comprehensive research of pediatric ventriculoperitoneal shunt infection