Antibiotic prophylaxis for patients with …

1 Antibiotic prophylaxis for patients with hydrocephalus shunts:a survey of pediatric dentistry and neurosurgery program directorsGeorge Acs, DMD, MPH Elise Cozzi, DMDA bstractA survey of Antibiotic prophylaxis recommendations for patients with hydrocephalus shunts was sent todirectors of advanced programs in pediatric dentistry and neurosurgery. Recommendations were sought forpatients with ventriculoperitoneal (VP) or ventriculoatrial (VA) shunts who were to receive dental care. respondents believed that shunt infection (SI) was related infrequently to dental procedures. Pediatricdentists believed that of infected VA shunts were related to dental procedures, while neurosurgeonsbelieved the rate to be (P < ).

2 There was no difference in perceived risk for VP shunts. Except for theequal risk associated with extractions, pediatric dentists were significantly more likely than neurosurgeons torecommend chemoprophylaxis for patients with VA shunts undergoing invasive dental procedures (P ). They were more likely to agree with neurosurgeons when VP shunts were involved. Except for the equalrisk associated with dental prophylaxis , pediatric dentists and neurosurgeons believed VA shunt patientswere at greater risk for SI than VP shunt patients (P < ). Pediatric dentists were significantly more likelyto ascribe SI to streptococcal organisms, and recommended penicillin for prophylaxis for both VA and VPshunts (P < and , respectively).

3 Although neurosurgeons believed that staphylococcal organismswere most likely to be responsible for SI (P < ), 60% still recommended using penicillin for shuntprophylaxis following dental procedures. (Pediatr Dent 14:246-50, 1992)IntroductionHydrocephalus is an enlargement of the ventricularsystem, which results from an imbalance between pro-duction and absorption of cerebrospinal fluid (CSF)within the brain-fluid It is a pathologiccondition caused either by overproduction of CSF orobstruction in the aqueducts connecting the may be passive ventricular enlargement result-ing from loss of surrounding brain tissue due to agingor cerebrovascular accident, abnormal development ofthe cisterna magna and its connections over the brainsurface, or insufficient CSF circulatory absorption causedby failure of either villi function or venous drainage ofarachnoidal incidence of hydrocephalus alone has been esti-mated as total The total incidence ofhydrocephalus in association with other disorders.

4 Suchas spina bifida, has been reported as (VA) shunts connecting the lateralventricles with the venous circulation were used widely,until they were supplanted by ventriculoperitoneal (VP)shunts. VP shunts empty CSF directly into the abdomi-nal cavity, thus bypassing the venous circulation. It isnow generally believed that patients with VP shunts areless likely to suffer serious morbidities, particularlythose associated with shunt infection (SI), than are pa-tients with VA , 5 Shunt infections are costly in terms of morbidity,human suffering, intellectual and neurologic deficitsand health care The incidence of SI has beenreported to range from 5 to 31%, with mortality ratesranging from 34 to 40%.

5 SI is most likely to occur in thefirst postoperative has been suggested that oral and nasopharyngealsources of staphylococci play a potential role in shuntinfections,8 but no shunt infections have been relateddirectly to dental procedures. However, VA shuntshave been assigned a "high relative risk rate forbacteremia-induced infections," while VP shunts havebeen classified as being of "moderate risk." High-riskpatients always require Antibiotic chemoprophylaxis,but the need for Antibiotic chemoprophylaxis for mod-erate risk patients is controversial, and consultati6nwith a child s physician is required before dental purpose of this study was to investigate therelative risks assigned to VA and VP shunts followingspecific dental procedures for bacteremia-induced shuntinfections, as defined by directors of pediatric dentistryand neurosurgery advanced educational.

6 The study sought to tabulate antibioticchemoprophylaxis recommendations for patients withhydrocephalus and MethodsA brief survey was mailed to directors of all accred-ited advanced educational programs in pediatric den-tistry and neurosurgery in the continental United PEDIATRIC DENTISTRY: JULY/AuGuST, 1992 ~ VOLUME 14, NUMBER 4 The survey sought to investigate shunt prophylaxisrecommendations for VA and VP shunts based on pro-cedures performed. Also, information was sought onthe putative organisms of shunt infection, and the per-ceived risk of shunt infection following dental contingency testing was performed onthe dependent variable of shunt prophylaxis , based onprocedure performed and differences in responses be-tween pediatric dentists and neurosurgeons.

7 Likewise, Antibiotic recommendations were evaluated based onspecialty. Differences in the perceived risk of shuntinfection were evaluated using Student s t-test. Rela-tive risk, a measure of individual respondent s differentrecommendations for chemoprophylaxis based uponthe type of shunt, was evaluated using McNemar s were returned by (N = 51) of all pedi-atric dental program directors. Neurosurgery directorsreturned (N = 63). There was no significant differ-ence in study prophylaxis Recommendations (Table 1)VA ShuntsExcept for "invasive oral surgery procedures," pedi-atric dental directors were significantly more likely torecommend chemoprophylaxis for routine dental pro-cedures for these patients .

8 Pediatric dentist andneurosurgeon respondentsagreed, with near unanimity,that invasive oral surgicalprocedures warranted anti-biotic prophylaxis . Pediatricdental respondents, however,unlike their neurosurgerycounterparts, were equallyunanimous in recommendingantibiotic prophylaxis forroutine restorative dentalprocedures and ShuntsThere were no significantdifferences in the incidenceof Antibiotic prophylaxis rec-ommendations for these pa-tients. More than 50% of re-spondents recommendedprophylaxis followinginvasive oral surgery proce-dures and Responsible for Shunt InfectionMost of the neurosurgery directors ( ) believedthat staphylococcal organisms were most likely respon-sible for VA shunt failure, compared to of pediat-ric dental directors (P < ).

9 When VP shunts wereconsidered, of neurosurgeons believed thatstaphylococcal organisms were responsible for shuntinfection, compared to of pediatric dentists (P ). Pediatric dentists were significantly more likelyto believe that streptococcal organisms were respon-sible for shunt failure due to Antibiotic (Table 2)Pediatric dentists were significantly more likely torecommend penicillin as the Antibiotic of choice forboth VA and VP shunts, recommending it nearly 100%of the time. (P < and P < , respectively).Although neurosurgery respondents were less likely torecommend penicillin, more than 60% did Risk (Table 3, next page)Relative risk is expressed in terms of the per cent ofrespondents recommending shunt prophylaxis for VAshunts, but not for VP shunts, for a specific the exception of noninvasive dental prophy-laxis, neurosurgeons are significantly more likely torecommend shunt prophylaxis for VA shunts than forTable 1.

10 Antibiotic prophylaxis recommendationsVA Shunts VP ShuntsProcedure Pediatric Dentists Neurosurgeons Pediatric Dentists NeurosurgeonsRestorative35( ) 19( )12( )9( )Extractions36( )36( )19( )27( )Prophylaxis17( )9( )4( )6( )Scaling36( )t17( ) 19( )20( ) P< , Chi-square --- , 1 df; * P< , Chi-square = , 1 df. P< , Chi-square = , 1 count (percentage) recommending shunt prophylaxis for VA and VP 2. Antibiotic of choice for shunt prophylaxisVA Shunts VP ShuntsAntibioticPediatric DentistsNeurosurgeonsPediatric DentistsNeurosurgeonsPenicillin31 ( ) 19 ( )15 ( )t19 ( )Other2 ( )11 ( )0 ( )6 ( ) P< , Chi-square -- , 1 df.