Empiric antibiotic prescription patterns vary substantially in children with cerebrospinal fluid (CSF) shunt infection, and overuse is not uncommon, a study has found.
The current Infectious Diseases Society of America (IDSA) guidelines recommend vancomycin combined with an antipseudomonal beta-lactam (eg, cefepime, ceftazidime, or meropenem) in most cases, adjusted based on local susceptibility patterns, according to the investigators.
Of the 181 children treated with empiric antibiotics, 155 (85.6 percent) received vancomycin, 65 (35.9 percent) cefazolin, 55 (30.4 percent) ceftriaxone, 43 (23.8 percent) cefotaxime, and 36 (19.9 percent) cefepime. [Pediatr Infec Dis J 2026;45:760-764]
Combinations of empiric antibiotic therapy were rarely administered to these children, with only seven (3.6 percent) for vancomycin plus cefepime, one (0.5 percent) for vancomycin plus meropenem, and none (0 percent) for vancomycin plus ceftazidime. Over the study period, evidence suggesting a change in antimicrobial coverage was noted.
“Although conducted before the publication of the 2017 IDSA guidelines and during an earlier era of stewardship implementation, the findings remain relevant today,” the investigators said.
“Empiric therapy for CSF shunt infections continues to represent a key opportunity for antimicrobial stewardship programs to evaluate institutional practices, ensure guideline concordance and promote appropriate antibiotic use,” they added.
Limitations
Notably, the study period (2007‒2015) represents a limitation. The analysed data precede hospital system harmonization and the maturation of antimicrobial stewardship programmes, which have both accelerated in the last decade, according to the investigators, adding that advances in informatics and electronic health records have contributed to consistent and targeted empiric antibiotic practices.
Moreover, the empiric antibiotic choices in this study were guided by the 2004 IDSA guidelines, which addressed adult central nervous system infections and provided limited guidance for paediatric shunt infections. The current 2017 guidelines were released after the study period and were not represented in the treatment patterns observed.
“These temporal factors should be considered when interpreting the generalizability of our findings to current practice,” the investigators said.
Overuse
The current findings also observed potential overuse in empiric antibiotic therapy for CSF shunt infection, which suggest a reduction in excessive antibiotic utilization.
Use of the Antibiotic Spectrum Index (ASI) as a benchmark, while nonvalidated, can be a useful tool for stewardship efforts.
“For instance, an ASI index over 13 might be used prospectively to flag potentially excessive antibiotic use,” the investigators said. “We did not observe a change in temporal trends in ASI at the individual institutions.”
This retrospective, observation cohort study was conducted at six tertiary care children’s hospitals, involving paediatric patients who developed first shunt infection following initial CSF shunt placement surgery between 2007 and 2012.
The use of antimicrobials as empiric therapy was the primary outcome. Empiric therapy was defined as any antibiotic order on the day prior, day or, and day after the neurosurgical procedure to treat the infection (ie, occurring before culture results typically guide antibiotic selection). From 2007 to 2015, analyses were made at the infection and hospital levels.
“Future research should assess current empiric treatment patterns in light of modern stewardship infrastructure, local antimicrobial susceptibility patterns, and updated clinical guidelines,” the investigators said.