Introduction: External ventricular drains (EVDs) monitor and manage increased intracranial pressure (ICP) in neurosurgical patients. EVD-related infection (ERI) is a serious complication linked to longer hospital stays and higher costs. This review aims to determine the overall incidence of ERI, identify key risk factors, compare the effectiveness of different EVD types, and analyze causative organisms. Methods: A comprehensive literature search was performed on public databases (PubMed/MEDLINE, Cochrane Library, and Google Scholar) from inception to 15 July 2025. The Newcastle–Ottawa Scale (NOS) tool and Cochrane tool (RoB-2) were used to assess the quality of included studies. A random-effects model was applied for all meta-analyses. Results: The overall incidence of ERI was 8.6% (95% CI 7.2–10.3%, I2 = 93%). The incidence was significantly lower in antibiotic-impregnated (ABI) EVDs (4.3%) compared to that in plain (9.4%) and silver-impregnated (SI) (10.5%) EVDs. In subgroup analysis, the overall incidence of ERI in studies conducted in the US was notably lower than that in the non-US countries (4.1% vs. 10.4%). In comparison to plain catheters, the use of AI EVDs was associated with reduced risk of ERI occurrence (OR = 0.43, 95% CI 0.28–0.67, I2 = 16%, p < 0.01), but there was no significant difference in the use of ABI EVDs over SI catheters (OR = 0.44, 95% CI 0.15–1.29, I2 = 5%, p = 0.13). In sensitivity analysis, compared to plain EVDs, SI EVDs were associated with a significantly reduced risk of ERI (OR = 0.58, 95% CI 0.38–0.88, I2 = 0%, p = 0.01). Placement of more than 1 EVD, CSF leakage, and extended catheter duration were significant risk factors for ERI. Our results revealed that ERI was associated with longer hospital and ICU LOS. The majority of infections were due to Gram-positive bacteria (65%). The Staphylococcus (49.8%), followed by Acinetobacter (7.6%), and Klebsiella (7%) species, and at lower classifications, CoNS (58%) were the most common causative organisms. Conclusions: Our findings suggest that both ABI and SI EVDs are more effective in preventing ERI than plain ones. However, due to limited data, there is no definitive evidence to favor ABI EVDs over SI EVDs. Further multicenter randomized controlled trials are necessary to validate these conclusions.
SEIFI et al. (Sun,) studied this question.