Peer-Review ReportCost Analysis of Antibiotic-Impregnated Catheters in the Treatment of Hydrocephalus in Adult Patients
Introduction
Since their introduction in the 1950s, cerebrospinal fluid (CSF) shunts have been the mainstay of hydrocephalus treatment (1, 2, 5, 7, 9). Despite improvements in preoperative and perioperative antibiotic therapy, 5%–15% of all shunts placed in North America become infected (1, 25, 27). The clinical consequences of shunt infections in pediatric and adult high-risk populations have been extensively described and include reduced intelligence quotient, psychomotor retardation, and seizures (1, 4, 10, 11, 28, 31, 32). Several independent risk factors have been identified, including patient age, etiology of hydrocephalus, duration of surgery, revision surgery, surgeon experience, preceding shunt infection, postoperative CSF leakage, and external ventricular drain (EVD) to shunt conversions (20). The direct medical cost of shunt infection has been reported to be $17,300 to $48,454, with an estimated total annual cost of $100 million (3, 12, 26, 28).
Antibiotic-impregnated shunts (AIS) were introduced with the aim of reducing the incidence of shunt-related infections. AIS catheters release antibiotics over the course of several weeks to prevent the colonization of shunt systems by gram-positive bacteria, which accounts for the preponderance of shunt infections (6, 20, 23, 27). To date, most published studies on this subject have shown a statistically significant reduction in shunt-associated infections when AIS catheters were employed; however, there has been some reluctance to adopt these systems because of their increased cost compared with conventional catheters (8, 11, 14, 17, 21, 25). The efficacy of AIS catheters in these studies was confined to pediatric patients. Less evidence exists supporting their utility in adult patients with hydrocephalus (13).
We recently reported a significant reduction in the incidence of shunt infection in adult patients with hydrocephalus after the categorical conversion to AIS catheters at our institution (13). We have now performed a retrospective cohort study and economic analysis to determine whether the use of AIS catheters in adult patients with hydrocephalus at our institution has been cost-effective.
Section snippets
Methods
All adult patients undergoing CSF shunt insertion over a 7-year period at the Johns Hopkins Hospital were retrospectively reviewed (2004–2009). In 2006, a categorical switch to AIS catheters (Bactiseal; Codman) was made by the senior author (D.R.). Before 2006, standard nonimpregnated shunt catheters were used. In 2006 and thereafter, AIS catheters were used in all cases regardless of patient characteristics. After the 250th consecutive AIS shunt system was implanted in February 2009, this
Patient Population
During the review period, 500 CSF shunt procedures were performed in adult patients with hydrocephalus. Of these operations, 240 (48%) were performed in men, and 260 (52%) were performed in women, with an age range of 21–93 years (mean 60 years ± 18). Underlying pathology included NPH in 378 (76%) patients and pseudotumor cerebri in 83 (17%) patients. A further 40 (8%) patients underwent shunt procedures for various obstructive and communicating hydrocephalus etiologies. A CSF shunt procedure
Discussion
In a retrospective analysis of our categorical conversion to AIS catheters in the treatment of hydrocephalus in adult patients at a tertiary medical center, we observed a 3.3-fold reduction in the incidence of shunt infection. This reduction in infection was associated with a significant reduction in infection-related resource use and direct medical costs. Although the three patients with AIS infection had more prolonged hospital courses and a greater mean infection-related cost per patient,
Conclusions
In a retrospective cohort study of 500 CSF shunt surgeries performed in adult patients with hydrocephalus, our categorical conversion to AIS catheters was associated with a significant reduction in infection-related medical costs within the first year after surgery. Although prospective randomized cost-utility studies are needed to confirm our observations, our results suggest that AIS catheters are cost-effective in the treatment of hydrocephalus in adult patients.
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Conflict of interest: Daniele Rigamonti is supported by the Swenson family foundation. Matthew McGirt is a consultant for Codman.