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cause of shunt infection This procedure is usually performed by a neurosurgeon, if possible The results of this procedure are sometimes helpful but not always determinate; the white blood cell (WBC) count can range from to 2,600 if the shunt is infected, and patients without infection can have up to 500 WBCs/mm3 In the absence of a positive culture result, many clinicians use more than 50 WBCs/mm3 in the presence of fever, shunt malfunction, and neurologic or abdominal symptoms to arrive at the diagnosis Gram stain of the fluid may be helpful in broadening antibiotic coverage if gram-negative organisms are present However, the Gram stain should not be used to narrow the usual antibiotic coverage until the culture and sensitivities of the causative organisms are obtained Most neurosurgeons are reluctant to perform shunt taps in patients with subtle neurologic complaints and vague infectious signs because of the purported risk of “seeding” the shunt with skin flora This risk has never been clearly defined prospectively, but in a neurologically normal child, it is prudent to perform a thorough fever workup for common infectious sources to avoid even a small risk of causing a shunt infection Patients with ventriculoperitoneal shunt (VPS) who complain of abdominal pain, with or without fever, may benefit from abdominal radiographs and ultrasound to search for a loculated CSF collection or pseudocyst, or visceral perforation Various permutations of medical and surgical therapy have been suggested for the treatment of proximal CSF shunt infections Medical therapy alone has been found to have a relatively low success rate compared with a combined medical– surgical approach Potential surgical interventions include immediate shunt replacement or the insertion of an extraventricular drainage (EVD) catheter, followed by delayed shunt revision The latter method improves the bacteriologic cure rate significantly, although it must be performed in an institution that is facile in managing and preventing infection of EVD catheters Distal shunt infections are treated with antibiotics and temporary externalization of the distal shunt catheter Medical therapy provided in the ED for children with suspected CSF shunt infections is limited to the administration of broad-spectrum IV antibiotics The antibiotics should be effective against S epidermidis, S aureus , and gramnegative organisms, as well as any organisms identified from previous infections, and expanded to treat Pseudomonas aeruginosa infections in severely ill patients A reasonable choice of empiric therapy is cefepime followed by vancomycin Ciprofloxacin can be substituted for Cefepime in patients with documented
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