**9. Recommendations in international guidelines**

The Infectious Diseases Society of America (IDSA) have issued guidelines for clinicians on reducing infections in patients with neurosurgical devices [24]. They say that "Use of antimicrobial-impregnated CSF shunts and CSF drains is recommended (strong recommendation, moderate confidence rating)." Similarly the Neurocritical Care Society published their guidelines for insertion and management of EVDs [101] and stated "We recommend using antimicrobial-impregnated catheters as part of a comprehensive management protocol to reduce the rate of VRI (strong recommendation; moderate-quality evidence)" These recommendations, and the qualityof-evidence assessments, were made before the latest RCT results were published in 2019 [69].

*Infections in Intracranial Pressure Management: Impact of New Technologies on Infection Rates DOI: http://dx.doi.org/10.5772/intechopen.110349*

#### **10. Reservoirs and intracranial pressure monitors**

Infection in ventricular access reservoirs is rare, but when it occurs it can result in ventriculitis [15]. However, direct ventricular access is available for administration of antimicrobials. There is no current antimicrobial materials approach to reservoir infections. Techniques for measurement and monitoring of intracranial pressure vary and again, those not dependent on EVD have a low infection rate [102, 103].

#### **11. Conclusions**

There has been a dramatic fall in the rate of infections associated with CSF shunts and EVDs over the past two decades. This has been due to a much greater understanding amongst clinicians of the underlying science and the causes of the infections, and has led to well-thought-out non-technological approaches such as care bundles. However, these need to be more widely adopted. Their effect has been enhanced by improvements in anti-infective technology that has centred on development of coated and impregnated devices, and certainly the latter have been shown to be highly effective in reducing further the infection rates as well as healthcare costs. An additional benefit to this approach has been the reduction in antibiotic use, leading to less drug resistance and adverse effects. The use of antimicrobial shunts and EVDs has now been recommended as the standard of care in neurosurgery. Problems remain, especially in EVD where increase in infections due to highly drug-resistant bacteria is seen, and these are not currently preventable by the impregnation technology. New formulations that have been shown to have activity against even the most drug-resistant EVD pathogens have been thoroughly evaluated in the laboratory, but as yet they have not been commercial adopted.

### **Conflict of interest**

The author is the inventor of the "Bactiseal" antimicrobial catheter, but he has not and does not receive any royalties or other payment. He receives speaker fees from Codman Inc., but not for personal gain and these are paid to his University.

*Frontiers in Hydrocephalus*
