# Is there a way to reduce the infection associated with external ventricular shunts? A systematic review and meta-analysis of the recent bundle of care

## TL;DR

This study finds that using a bundle of care measures can reduce infections from external ventricular drains but does not affect mortality or hospital stay.

## Contribution

The study evaluates the effectiveness of a bundle of care for reducing EVD-related infections through a systematic review and meta-analysis.

## Key findings

- Bundle care significantly reduced infection risk and drain stay duration.
- No significant effect on mortality or ventriculitis rates was observed.
- The study supports standardized care bundles but highlights the need for further research on specific complications.

## Abstract

Background: Although external ventricular drains (EVDs) are crucial in neurosurgical care, they carry a high risk of healthcare-associated ventriculitis, with reported infection rates. Numerous interventions were thought to aid in infection control, but there is still an ongoing increase in infection incidence. Recently, bundled interventions with standardized protocols, antimicrobial‐impregnated catheters, tunneling techniques, chlorhexidine dressings, and limited antibiotic prophylaxis have shown an interesting efficacy in shunt-related infection control. Methods: A systematic review was conducted using PubMed, Scopus, Google Scholar, Cochrane CENTRAL, and Web of Science to search for published articles on care bundles with at least three discrete preventive measures. Data analysis was performed using R software, estimating mean difference and risk ratios. Results: Seventeen studies (9 quasi-experimental, 6 retrospective, and 2 prospective cohorts) were included in this study. Implementation of bundle care was associated with a significant reduction in the following outcomes: infection risk and drain stay duration (pooled RR = 0.32; 95% CI 0.20–0.51; p = 0.0001; I²=73.7%), (pooled MD=-1.57; 95% CI -5.80–2.67; p = 0.0038; I²=0%), respectively. Interestingly, there was no significant difference in risk with bundle of care regarding mortality (pooled RR = 1.09; 95% CI 0.62–1.92; p = 0.6924; I²=63.5%). However, no significant differences were observed in ventriculitis rates or hospital stay duration, with p = 0.0509, p = 0.3855, respectively. Conclusions: Bundle of care implementation significantly reduced infection risk and drain days among patients with external ventricular drains, but failed to reduce ventriculitis, mortality, and hospital stay duration. These findings support approving standardized care bundles to improve outcomes, though further high-quality research is needed to assess their impact on specific complications like ventriculitis, mortality, and hospital stay.

The online version contains supplementary material available at 10.1007/s10143-025-04029-4.