Multidrug-resistant bacteria drive one in five VP shunt infections in Pakistan

One in five patients who received a ventriculoperitoneal shunt at a tertiary care centre in Pakistan developed a shunt infection, and the organisms responsible were predominantly multidrug-resistant Gram-negative bacteria, according to a retrospective cohort study published in BMC Infectious Diseases. The findings, drawn from 200 patients with complete records who underwent VP shunt surgery between January 2018 and December 2024, add to emerging data from South Asia suggesting a shift toward Gram-negative pathogens in infections of cerebrospinal fluid diversion devices.

In this predominantly paediatric cohort, 42 of the 200 patients developed a shunt infection, an overall rate of 21.0 percent with a 95 percent confidence interval of 15.9 to 27.2 percent. The timing was strongly front-loaded: cumulative incidence estimated by the Kaplan-Meier method reached 13.0 percent within 30 days of surgery and 20.1 percent by 12 months, meaning most infections declared themselves in the immediate postoperative period.

To identify who was most at risk, the researchers used LASSO-penalised Cox regression to select candidate variables and then fitted a multivariable Cox proportional hazards model with bootstrap internal validation. Two factors emerged as independently associated with infection. Non-communicating hydrocephalus roughly doubled the hazard of infection, with an adjusted hazard ratio of 2.08 (95 percent CI 1.07 to 4.07). A previous central nervous system infection carried an adjusted hazard ratio of 2.39 (95 percent CI 1.11 to 5.17). The authors caution, however, that the model’s discrimination was modest, with an optimism-corrected C-index of 0.61, and that these risk factors require confirmation in larger prospective cohorts.

The microbiological spectrum was the study’s most striking finding. Gram-negative organisms accounted for 59.5 percent of infections, led by Acinetobacter species at 23.8 percent. Resistance was extensive: 20 of the 25 Gram-negative isolates were classified as multidrug-resistant or extensively drug-resistant. Susceptibility testing showed the highest activity for colistin at 91 percent and the lowest for ceftazidime at just 9 percent, while meropenem and piperacillin-tazobactam retained susceptibility in 68 percent and 52 percent of isolates respectively. Among the Gram-positive pathogens, 9 of 11 staphylococcal isolates, or 82 percent, were methicillin-resistant.

Clinical outcomes were sobering. In-hospital mortality among patients with shunt infection stood at 19.0 percent, and all eight deaths occurred in patients who had developed ventriculitis or a brain abscess. The authors conclude that empirical antibiotic therapy should be guided by local antibiogram data.

As a retrospective single-centre study, the analysis has inherent limitations, including reliance on complete records only and the modest predictive performance of the risk model. Even so, the combination of a 21 percent infection rate, a predominance of multidrug-resistant Gram-negative organisms and high methicillin resistance among staphylococci points to a serious clinical problem at this centre. The researchers suggest that non-communicating hydrocephalus and previous central nervous system infection may help identify patients at higher risk, while stressing that larger prospective studies are needed before such targeting can be relied upon.

Subject of Research: Clinical and microbiological outcomes of ventriculoperitoneal shunt infections in Pakistan

Article Title: Ventriculoperitoneal shunt infections in Pakistan: a retrospective cohort study of clinical and microbiological outcomes

Article References: Ullah, I., Shah, S. S., Khan, M. N., Shafique, S., Riaz, F., Khan, Z., & Ullah, H. (2026). Ventriculoperitoneal shunt infections in Pakistan: a retrospective cohort study of clinical and microbiological outcomes. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14660-1

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14660-1

Keywords: ventriculoperitoneal shunt, shunt infection, hydrocephalus, multidrug resistance, Acinetobacter, Gram-negative bacteria, methicillin-resistant staphylococci, ventriculitis, Pakistan, retrospective cohort study, antimicrobial resistance, neurosurgery