Routine management

Antibiotic prophylaxis is not routinely required for individuals with shunts for hydrocephalus.

Occurrence of shunt infections has not been linked with dental procedures and the theoretical risk appears negligible.

There is no specific UK guidance relating to shunts and a need for antibiotic prophylaxis.

UK antimicrobial prescribing guidance for other groups potentially at risk of bacteraemia-induced infection from dental procedures is that antibiotic prophylaxis is not routinely recommended.

Non-routine management

To determine individual instances where prophylaxis may be warranted, consider:

• the nature of the dental treatment and risk of transient bacteraemia, and
• type of shunt and risk of bacteraemia-induced shunt infection.

The type of shunt should be confirmed with the individual or GP. Seek clarification from their neurologist if necessary.

Nature of dental treatment

Dental procedures can be invasive (e.g. abscess draining, tooth extractions or implant placement) or non-invasive (e.g. supra-gingival scale and polish, removal of sutures or radiographs).

Invasive dental procedures

Invasive procedures can cause transient bacteraemia. However, the magnitude and frequency of this bacteraemia is less than that caused during normal oral function (e.g. tooth brushing, dental flossing and chewing). Antibiotic prophylaxis is not considered necessary unless the individual has other clinical risk factors as described by UK antimicrobial prescribing guidance.

Non-invasive dental procedures

Non-invasive procedures do not pose the same risk of generating transient bacteraemia making antibiotic prophylaxis unnecessary.

Type of Shunt

There are many different types of shunt which divert cerebrospinal fluid to different parts of the body.

If a shunt has vascular access, there is a theoretical concern that transient bacteraemia could travel to the shunt and cause infection. This risk is considered negligible.

If a shunt does not have vascular access, there is no risk from transient bacteraemia.

Shunts with vascular access

Ventriculoatrial (VA) shunts have vascular access. They are rarely used in the UK.

Need for prophylaxis

Prophylactic antibiotics should not be routinely prescribed.

Use your clinical judgement to determine if there is a sufficient need. Consider the individual’s opinion and preference along with their clinical history.

Seek specialist neurology input if required.

Shunts without vascular access

Ventriculoperitoneal (VP) shunts are the most widely used shunt in the UK.

Less commonly seen shunts without vascular access are lumboperitoneal (LP) and ventriculopleural (VPL) shunts.

Need for prophylaxis

Prophylactic antibiotics are not required.

Occurrence of shunt infections

Dental origin

To date, there has been no case of a dental procedure causing a shunt infection reported in the literature.

Oral bacteria have been present only in a very small number of shunt infections and even then, only as part of a mixed infection.

Other sources

Most shunt infections occur within two months of placement because of bacteria from the skin or air entering the shunt or cerebrospinal fluid during surgery or afterwards during healing.

Ventriculoperitoneal (VP) shunts can also be infected after local injury and occasionally from peritonitis, appendicitis, or perforation of the bowel.