**8. Surgical bundles with antimicrobial devices**

Despite the very positive findings showing the effectiveness of antimicrobial catheters in prevention of infection in both shunts and EVDs, it would be wrong to assume that other aspects of surgical procedures can be relaxed. The best approach would be to ensure that a robust surgical bundle was instituted along with adoption of an antimicrobial catheter. This was clearly illustrated by a study in which, after a preliminary period to establish a baseline, a completely new surgical bundle was introduced, that included rigorous aseptic technique and intensive staff training, and an antimicrobial EVD catheter [100]. The infection rate fell sequentially each quarter, from baseline of 9.2 to 2.6%, then to 0% over 4 years. In such a study, it is impossible to say whether the antimicrobial catheter alone, or the bundle alone, was responsible but it is likely that a combination of the two brought about the dramatic and sustained fall in infection rates.
