Abstract：
OBJECTIVE: Cerebrospinal fluid (CSF) white blood cell (WBC) count, neutrophil percentage, protein concentration, and glucose level are typically measured at diagnosis and serially during the treatment of CSF shunt infections. The objective of this retrospective cohort study was to describe the longitudinal profile of CSF parameters in children with CSF shunt infections and assess their association with treatment and outcome.
METHODS: Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed.
RESULTS: A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%-2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest with Cutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030).
CONCLUSIONS: A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.
METHODS: Participants were children treated at 11 tertiary pediatric hospitals in Canada and the United States for CSF shunt infection, from July 1, 2013, through June 30, 2019, with hardware removal, external ventricular drain placement, intravenous antibiotics, and subsequent permanent shunt reinsertion. The relationship between CSF parameters and a complicated course (a composite outcome representing children with at least one of the following: contiguous soft-tissue infection, worsening hydrocephalus, CSF leak, intracranial bleed, brain abscess, venous thrombosis, reinfection after insertion of the new shunt, other complication, ICU admission, or death) was analyzed.
RESULTS: A total of 109 children (median age 2.8 years, 44% female) were included in this study. CSF pleocytosis, elevated protein, and hypoglycorrhachia had sensitivities of 69%, 47%, and 38% for the diagnosis of culture-confirmed CSF shunt infection, respectively. The longitudinal profile of the neutrophil percentage followed a monotonic trend, decreasing by 1.5% (95% CI 1.0%-2.0%, p < 0.0001) per day over the course of treatment. The initial WBC count differed significantly between pathogens (p = 0.011), but the proportion of neutrophils, protein concentration, and glucose level did not, and was lowest with Cutibacterium acnes. The duration of antibiotic treatment and the time to shunt reinsertion were longer in patients with a higher initial neutrophil percentage. Fifty-eight patients (53%) had one or more complications during their admission. A neutrophil percentage > 44% (Youden index) in the initial CSF sample was associated with a 1.8-fold (95% CI 1.2- to 2.8-fold) higher relative risk of a complicated course. In a random-intercept, random-slope linear mixed-effects model, the longitudinal neutrophil trajectory differed significantly between patients with and without complications (p = 0.030).
CONCLUSIONS: A higher proportion of neutrophils in the CSF at diagnosis was associated with a complicated clinical course. Other CSF parameters were associated with treatment and outcome; however, wide variability in values may limit their clinical utility.
摘要：
目的：脑脊液（CSF）白细胞（WBC）计数，中性粒细胞百分比，蛋白质浓度，和葡萄糖水平通常在诊断时和在CSF分流感染的治疗期间连续测量。这项回顾性队列研究的目的是描述CSF分流感染患儿的CSF参数的纵向分布，并评估其与治疗和预后的关系。
方法：参与者是在加拿大和美国的11家三级儿科医院接受CSF分流感染治疗的儿童，从2013年7月1日至2019年6月30日，随着硬件的拆卸，外部心室引流放置，静脉注射抗生素,以及随后的永久性分流器重新插入。CSF参数与复杂病程之间的关系（复合结局代表以下至少一种情况的儿童：连续的软组织感染，脑积水恶化，脑脊液渗漏,颅内出血,脑脓肿,静脉血栓形成,插入新的分流管后再感染,其他并发症,入住ICU,或死亡）进行了分析。
结果：共有109名儿童（中位年龄2.8岁，44％的女性）被纳入本研究。CSF细胞增多，蛋白质升高，低血糖的敏感性为69%，47%,38%用于诊断培养证实的脑脊液分流感染，分别。中性粒细胞百分比的纵向分布遵循单调趋势，下降1.5%（95%CI1.0%-2.0%，p<0.0001）在治疗过程中每天。病原体之间的初始白细胞计数差异显著(p=0.011)，但是中性粒细胞的比例，蛋白质浓度，葡萄糖水平没有，和最低的粉刺杆菌。初始中性粒细胞百分比较高的患者的抗生素治疗持续时间和分流再插入时间更长。58例患者（53％）在入院期间出现了一种或多种并发症。初始CSF样本中中性粒细胞百分比>44％（Youden指数）与复杂病程的相对风险较高1.8倍（95％CI1.2至2.8倍）相关。在随机截获中，随机斜率线性混合效应模型，中性粒细胞的纵向轨迹在有和无并发症的患者之间有显著差异(p=0.030).
结论：诊断时脑脊液中中性粒细胞比例较高与复杂的临床过程有关。其他CSF参数与治疗和结果相关；然而，值的广泛变化可能会限制其临床应用。
方法：参与者是在加拿大和美国的11家三级儿科医院接受CSF分流感染治疗的儿童，从2013年7月1日至2019年6月30日，随着硬件的拆卸，外部心室引流放置，静脉注射抗生素,以及随后的永久性分流器重新插入。CSF参数与复杂病程之间的关系（复合结局代表以下至少一种情况的儿童：连续的软组织感染，脑积水恶化，脑脊液渗漏,颅内出血,脑脓肿,静脉血栓形成,插入新的分流管后再感染,其他并发症,入住ICU,或死亡）进行了分析。
结果：共有109名儿童（中位年龄2.8岁，44％的女性）被纳入本研究。CSF细胞增多，蛋白质升高，低血糖的敏感性为69%，47%,38%用于诊断培养证实的脑脊液分流感染，分别。中性粒细胞百分比的纵向分布遵循单调趋势，下降1.5%（95%CI1.0%-2.0%，p<0.0001）在治疗过程中每天。病原体之间的初始白细胞计数差异显著(p=0.011)，但是中性粒细胞的比例，蛋白质浓度，葡萄糖水平没有，和最低的粉刺杆菌。初始中性粒细胞百分比较高的患者的抗生素治疗持续时间和分流再插入时间更长。58例患者（53％）在入院期间出现了一种或多种并发症。初始CSF样本中中性粒细胞百分比>44％（Youden指数）与复杂病程的相对风险较高1.8倍（95％CI1.2至2.8倍）相关。在随机截获中，随机斜率线性混合效应模型，中性粒细胞的纵向轨迹在有和无并发症的患者之间有显著差异(p=0.030).
结论：诊断时脑脊液中中性粒细胞比例较高与复杂的临床过程有关。其他CSF参数与治疗和结果相关；然而，值的广泛变化可能会限制其临床应用。
