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Association of cerebrospinal fluid parameters with treatment and complications among children with cerebrospinal fluid shunt infections: a multicenter study

Michael T. Hawkes Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada;

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Alastair McAlpine Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada;

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Michelle Barton Department of Pediatrics, London, Health Sciences Centre, Western University, London, Ontario, Canada;

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Adrianna Ranger Department of Pediatrics, London, Health Sciences Centre, Western University, London, Ontario, Canada;

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Archana Balamohan Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas;

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H. Dele Davies Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska;

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Gwenn Skar Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska;

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Marie-Astrid Lefebvre Department of Pediatrics, McGill University, Montréal, Québec, Canada;

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Ahmed Almadani Department of Pediatrics, McGill University, Montréal, Québec, Canada;

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Dolores Freire Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada;

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Nicole Le Saux Department of Pediatrics, University of Ottawa, Ontario, Canada;

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Jennifer Bowes Department of Pediatrics, University of Ottawa, Ontario, Canada;

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Jocelyn A. Srigley Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada;

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Patrick Passarelli Department of Pediatrics, UC San Diego School of Medicine, San Diego, California;

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John Bradley Department of Pediatrics, UC San Diego School of Medicine, San Diego, California;

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Sarah Khan Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada;

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Rupeena Purewal Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and

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Isabelle Viel-Thériault Department of Pediatrics, CHU de Québec-Université Laval, Québec, Québec, Canada

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Joan L. Robinson Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada;

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for the Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC)
Publication Date:
13 Oct 2023
Page Range:
1–9
Volume/Issue:
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DOI link:
https://doi.org/10.3171/2023.8.PEDS23348
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OBJECTIVE

脑脊液(CSF)白细胞(WBC) count, neutrophil percentage, protein concentration, and glucose level are typically measured at diagnosis and serially during the treatment of CSF shunt infections. The objective of this retrospective cohort study was to describe the longitudinal profile of CSF parameters in children with CSF shunt infections and assess their association with treatment and outcome.

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Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed.

RESULTS

A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%–2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest withCutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030).

CONCLUSIONS

A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.

ABBREVIATIONS

AUROC = area under the ROC curve ; CoNS = coagulase-negative staphylococci ; CSF = cerebrospinal fluid ; EVD = external ventricular drain ; ICU = intensive care unit ; IDSA = Infectious Diseases Society of America ; LME = linear mixed-effects ; ROC = receiver operating characteristic ; RR = relative risk ; WBC = white blood cell.

Supplementary Materials

    • Supplemental Figures and Table (PDF 660 KB)
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Contributor Notes

CorrespondenceJoan L. Robinson: University of Alberta, Edmonton, AB, Canada.jr3@ualberta.ca.

INCLUDE WHEN CITINGPublished online October 13, 2023; DOI: 10.3171/2023.8.PEDS23348.

DisclosuresDr. Skar reported a grant from the National Institutes of Health National Institute of Neurological Disorders and Stroke (no. K08NS110923) outside the submitted work. Dr. Robinson reported payment for peer review from Elsevier outside the submitted work.
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