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.

Confirm shunt type with the individual or GP. Seek clarification from their neurologist if necessary.

Nature of dental treatment

Dental procedures can be invasive or non-invasive. Examples of invasive procedures include abscess draining, tooth extractions or implant placement. Non-invasive procedures include 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 bacteraemia is less than that caused during normal oral function such as tooth brushing, dental flossing and chewing. Antibiotic prophylaxis is unnecessary 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 shunts which divert cerebrospinal fluid (CSF) to different parts of the body.

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

Shunts without vascular access carry no risk from dental-induced transient bacteraemia.

Shunts with vascular access

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

Need for prophylaxis

Do not routinely prescribe prophylactic antibiotics for invasive dental procedures.

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), ventriculopleural (VPL) and ventriculosubgaleal (VSG) shunts.

Need for prophylaxis

Prophylactic antibiotics are not required for invasive dental procedures.

Shunt infections

A shunt infection is a serious complication that may require the shunt’s removal and replacement.

Dental origin

To date, there are no literature reports of dental procedures causing shunt infections.

Oral bacteria have been present in a very small number of shunt infections but only as part of a mixed infection.

Other sources

Most shunt infections occur within three months of placement. Bacteria from the skin or air can enter the shunt or CSF during or after surgery or during healing, leading to infection.

Ventriculoperitoneal (VP) shunts can also be infected after local injury, occasionally from peritonitis or appendicitis or following bladder or bowel surgery.

Bibliography

Full referencing is available on request.

Update history