External ventriculostomy-associated infection reduction after updating a care bundle

BACKGROUND: Despite the clinical benefits of external ventricular drains (EVD), these devices can lead to EVD-related infections (EVDRI). The drainage insertion technique and standardized guidelines can significantly reduce the risk of infection, mainly caused by gram-positive bacteria. However, gram-negative microorganisms are the most frequent causative microorganisms of EVDRI in our hospital. We aimed to determine whether a new bundle of measures for the insertion and maintenance of a drain could reduce the incidence of EVDRI. This cohort study of consecutive patients requiring EVD from 01/01/2015 to 12/31/2018 compared the patients’ characteristics before and after introducing an updated protocol (UP) for EVD insertion and maintenance in 2017. RESULTS: From 204 consecutive patients, 198 requiring EVD insertion were included (54% females, mean age 55 ± 15 years). The before-UP protocol included 87 patients, and the after-UP protocol included 111 patients. Subarachnoid (42%) and intracerebral (24%) hemorrhage were the main diagnoses at admission. The incidence of EVDRI fell from 13.4 to 2.5 episodes per 1000 days of catheter use. Gram-negative bacteria were the most frequent causative microorganisms. Previous craniotomy remained the only independent risk factor for EVDRI. EVDRI patients had increased mechanical ventilation durations, hospital and ICU stays, and percutaneous tracheostomy requirements. CONCLUSIONS: A care bundle focusing on fewer catheter sampling and more accurate antiseptic measures can significantly decrease the incidence of EVDRI. After implementing the management protocol, a decreased incidence of infections caused by gram-negative and gram-positive bacteria and reduced ICU and hospital lengths of stay were observed.