Antibiotic prophylaxis in craniotomy: a review

Questionnaire-based Survey on the Prevention of Surgical Site Infection after the Publication of Its Guidelines for Neurosurgery in Japan

In recent years, the Japanese neurosurgical field has been added to the guidelines for the appropriate use of antimicrobial agents for the prevention of surgical site infection; however, the awareness of neurosurgeons and specific methods for surgical site infection prevention in the Japanese neurosurgical field remains unclear. Therefore, we report a repeat survey conducted after the addition of guidelines on the appropriate use of antimicrobial agents for the prevention of surgical site infection and compare it with our previous survey on surgical site infection prevention conducted in 2018. A questionnaire-based survey was conducted via the Internet among members of the Japanese Neurosurgical Society and the Japanese Society of Chemotherapy. The survey response rate was 34.1% (270/792). More than 90% of the respondents were facility directors or specialists, and their institutions were universities and private hospitals. Cefazolin sodium was used in 88% of cases, and the percentage of cases started immediately before surgery increased to 85% (65% in the previous survey). Intraoperative administration intervals were most frequent every 3 hours (62%). Preoperative hair washing was performed by 76% of patients, a rate lower than that reported in the previous survey. Approximately 89% used partial removal, 75% used povidone-iodine for surgical field disinfection, double gloves were used by 46%, and antibacterial sutures by only 36% of surgeons. Compared with the 2018 survey, improvements were observed in the use of antibiotics for which guidelines were developed; however, other aspects of surgical site infection prevention need to be clarified, and guidelines for surgical site infection in the field of neurosurgery are necessary.

Surgical and procedural antibiotic prophylaxis in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).

Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review

INTRODUCTION

Postoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application.

METHODS

A literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL).

RESULTS

Twelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n=8). Non-opioid analgesia in ERAS improved postoperative pain control (n=4) and decreased the duration of pain (n=1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL.

CONCLUSION

Implementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.

Revisiting the Role of Surgical Resection for Brain Metastasis

Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed. Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.

Preparation of Isopropyl Acrylamide Grafted Chitosan and Carbon Bionanocomposites for Adsorption of Lead Ion and Methylene Blue

Wastewater, which is rich with heavy elements, dyes, and pesticides, represents one of the most important environmental pollutants. Thus, it has been significant to fabricate environmentally friendly polymers with high adsorption ability for those pollutants. Herein, crosslinked chitosan (C-Cs) was prepared using isopropyl acrylamide and methylene bisacrylamide. Carbon nanoparticles (C-NPs) were also obtained by the treatment of the agricultural wastes, which was used with C-Cs to prepare C-Cs/C-NPs nanocomposite (C-Cs/C-NC). Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), and transmission electron microscope (TEM) were used to investigate the prepared adsorbent. C-Cs, C-NPs, and C-Cs/C-NC were used in water treatment for the adsorption of lead ions (Pb⁺²) and methylene blue (MB). The adsorption process occurred by the prepared samples was investigated under different conditions, including contact time, as well as different doses and concentrations of adsorbents. The findings exhibited that the adsorption of Pb⁺² and MB by C-Cs/C-NC was higher than C-Cs and C-NPs. In addition, the kinetic and isotherm models were studied, where the results showed that the adsorption of Pb⁺² and MB by various adsorbents obeys pseudo-second-order and Langmuir isotherms, respectively.

Cefazolin Loaded Oxidized Regenerated Cellulose/Polycaprolactone Bilayered Composite for Use as Potential Antibacterial Dural Substitute

Oxidized regenerated cellulose/polycaprolactone bilayered composite (ORC/PCL bilayered composite) was investigated for use as an antibacterial dural substitute. Cefazolin at the concentrations of 25, 50, 75 and 100 mg/mL was loaded in the ORC/PCL bilayered composite. Microstructure, density, thickness, tensile properties, cefazolin loading content, cefazolin releasing profile and antibacterial activity against S. aureus were measured. It was seen that the change in concentration of cefazolin loading affected the microstructure of the composite on the rough side, but not on the dense or smooth side. Cefazolin loaded ORC/PCL bilayered composite showed greater densities, but lower thickness, compared to those of drug unloaded composite. Tensile modulus was found to be greater and increased with increasing cefazolin loading, but tensile strength and strain at break were lower compared to the drug unloaded composite. In vitro cefazolin release in artificial cerebrospinal fluid (aCSF) consisted of initial burst release on day 1, followed by a constant small release of cefazolin. The antibacterial activity was observed to last for up to 4 days depending on the cefazolin loading. All these results suggested that ORC/PCL bilayered composite could be modified to serve as an antibiotic carrier for potential use as an antibacterial synthetic dura mater.

Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study

Pediatric neurosurgery is a highly specialized branch of surgery in which surgical site infections (SSIs) are potentially serious complications that can also adversely affect a good surgical outcome, compromising functional recovery and, in some cases, even putting the patient’s life at risk. The main aim of this consensus document is to provide clinicians with a series of recommendations on antimicrobial prophylaxis for neonates and children undergoing neurosurgery. The following scenarios were considered: (1) craniotomy or cranial/cranio-facial approach to craniosynostosis; (2) neurosurgery with a trans-nasal-trans-sphenoidal approach; (3) non-penetrating head injuries; (4) penetrating head fracture; (5) spinal surgery (extradural and intradural); (6) shunt surgery or neuroendoscopy; (7) neuroendovascular procedures. Patients undergoing neurosurgery often undergo peri-operative antibiotic prophylaxis, with different schedules, not always supported by scientific evidence. This consensus provides clear and shared indications, based on the most updated literature. This work has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, and represents, in our opinion, the most complete and up-to-date collection of recommendations on the behavior to be held in the peri-operative setting in this type of intervention, in order to guide physicians in the management of the patient, standardize approaches and avoid abuse and misuse of antibiotics.

Nanopore 16S sequencing enhances the detection of bacterial meningitis after neurosurgery

Objective

Nosocomial bacterial meningitis is one of the major complications after neurosurgery. We performed nanopore 16S amplicon sequencing from cerebrospinal fluid (CSF) to evaluate bacterial meningitis in patients who underwent neurosurgery.

Methods

Among the patients who visited the neurosurgery department of Seoul National University Hospital between July 2017 and June 2020, those with clinically suspected bacterial meningitis were included. 16S rDNA PCR was performed from the CSF, and nanopore sequencing was performed for up to 3 h. The reads were aligned to the BLAST database. In each case, the culture and the 16S rRNA gene amplicon analysis were simultaneously performed and compared with each other, and we retrospectively reviewed the medical records. Genuine infection was determined by the identical results between conventional culture study and the sequencing, or clinically determined in cases with inconsistent results between the two methods.

Results

Of the 285 samples obtained from 178 patients who had 16S rDNA PCR, 41 samples (14.4%) were diagnosed with genuine infection. A total of 56.1% (23/41) of the samples with genuine infection showed a false‐negative culture test. In particular, 16S amplicon sequencing was useful in evaluating patients at the initial tests who had infection with intraventricular hemorrhage (Culture false‐negative rate = 100%), subarachnoid hemorrhage (Culture false‐negative rate = 77.8%), and systemic cancer (Culture false‐negative rate = 100%), which are risk factors for central fever. Moreover, 16S amplicon sequencing could suggest the possibility of persistent bacterial meningitis in empirical antibiotic use.

Conclusion

CSF nanopore 16S sequencing was more effective than conventional CSF culture studies in postoperative bacterial meningitis and may contribute to evidence‐based decisions for antibiotic maintenance and discontinuation.

Survey of Prophylactic use of Antibiotics among Indian Neurosurgeons

Background

Despite recommendations and guidelines, surgical antibiotic prophylaxis protocol for neurosurgical cases is not uniformly followed.

Objective

To report trends in the use of prophylactic antibiotics by Indian neurosurgeons for non-trauma neurosurgical cases.

Materials and Methods

An email survey consisting of 17 questions was sent in 2018 to 2,175 surgical members with a registered email in the Neurological Society of India (NSI) registry. Three reminders were sent at 3-month intervals. The results were analyzed for the number, type, and duration of antibiotic use for different surgical procedures. The differences in the antibiotic policy in different practice settings were also studied.

Results

The response rate was less than 5% (103 responses). Almost all (98.1%) surgeons used prophylactic antibiotics. A single antibiotic was most used for cranial surgeries (85%) and least for spine surgeries with instrumentation (64%) (P = 0.001). One dose or 1 day of antibiotics was used by the least number of responders (29%) for spinal instrumentation surgeries and the most responders (66.7%) for spinal surgery without instrumentation (P < 0.0001). Surgeons working in corporate teaching hospitals or non-teaching hospitals were more likely to use antibiotics for longer duration than surgeons working in government/trust teaching hospitals.

Conclusions

Substantial numbers of surgeons use prophylactic antibiotics for more than 1 day with a higher proportion of surgeons working in corporate teaching and non-teaching hospitals pursuing such a policy.

Preoperative antibiotic prophylaxis regimen in brain tumour surgery in Sweden: a quasi-experimental study

Background

There has been varied clinical practice concerning antibiotic prophylaxis in patients undergoing craniotomy. In Sweden, both Cloxacillin and Cefuroxime have frequently been used. We aimed to study the clinical effectiveness of these two regimens.

Methods

A quasi-experimental design was used. The sample consisted of 580 adult (> 18 years) patients operated 2012–2015, of which 375 received Cloxacillin (pre-intervention group) and 205 received Cefuroxime (intervention group). Primary endpoint was the incidence of surgical site infection (SSI) 12 months after surgery, while secondary endpoints were the need for reoperation due to SSI, the amount antibiotics used and the number of visits in the outpatient clinic related to SSI. A control group from another institution was reviewed to rule out clinical trial effects.

Results

When analysed by intention to treat, the pre-intervention group had a significant higher incidence of SSI, 13.3% (50/375) vs 5.4% (11/205) in the intervention group (p < 0.01). A treatment per protocol analysis confirmed the result. The number of reoperations due to SSI were significantly reduced in the intervention group, 3.4% (7/205) vs 8.3% (31/375) (p = 0.02), as was the total antibiotic use (p = 0.03) and the number of visits in the outpatient clinic (p < 0.01). In the control group, the reoperation rate as result of SSI was lower (p = 0.02) prior to the opposite change from Cefuroxime to Cloxacillin, 1.8% (27/1529) vs 3.1% (43/1378).

Conclusion

In Sweden, Cefuroxime as prophylaxis in brain tumour surgery by craniotomy seems to be superior to Cloxacillin.

Indirect comparison of efficacy between different antibiotic prophylaxis against the intracranial infection after craniotomy

BACKGROUND

Many studies had shown that prophylactic use of antibiotics could significantly reduce the intracranial infection (ICI) rate of craniotomy. However, there has been no comparison of these antibiotics.

METHODS

An electronic database search was performed, from inception to June 102,020. Randomized controlled trials (RCT) using different intravenous antibiotics (IVA) against the ICIs after craniotomy were considered. The primary outcome was the incidence rates of ICIs. An indirect treatment comparison (ITC) was conducted to compare the protective effect among the diverse antibiotic prophylaxis to prevent ICIs after craniotomy. Risk of potential bias was assessed.

RESULTS

A total of 3214 patients after craniotomy in 11 studies were included, 159 patients experienced postoperative ICI, including 33 patients in the antibacterial group and 126 in the control group. The calculate results of meta-analysis showed that except fusidic acid, preoperative intravenous injection of cephalosporin, clindamycin, vancomycin, and penicillin can significantly reduce the incidence of ICI after craniotomy, and ITC showed there was no statistically significance difference in the rates of post craniotomy ICI between the various antibiotics.

CONCLUSION

The current evidence shows that low-grade antibacterial drugs can be selected to prevent ICI after craniotomy, but this may be due to the limited number of studies per antibiotic. It still needs more high-quality, large sample RCT to confirm.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42019133369.

Acupuncture attenuates postoperative inflammation in patients after craniotomy: A prospective, open-label, controlled trial

BACKGROUND

It is important to manage inflammation after craniotomy. It may be prudent to reduce the excessive usage of antibiotics and to add supplementary treatments like acupuncture, which would be effective and safe. However, there are only a few studies available to date on the effects of acupuncture on anti-inflammatory response after craniotomy. The aim of this study was to explore the anti-inflammatory effects of acupuncture in patients after a craniotomy.

METHODS

This study was a single-center, prospective, open-label, controlled trial. Forty-four subjects who underwent craniotomy for an unruptured aneurysm, facial spasm, or brain tumor were allocated to either an acupuncture group or a control group. Both groups received postoperative routine care in the Department of Neurosurgery. The subjects in the acupuncture group also received a total of 6 acupuncture treatments sessions within 8 days after craniotomy. Acupuncture treatments included acupuncture, electroacupuncture, and intradermal acupuncture. The serum interleukin (IL)-1β and IL-6, tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), and erythrocyte sedimentation rate levels were assessed four times within 7 days after surgery. The presence of fever, use of additional antibiotics, presence of infection including pneumonia or urinary tract infection, and safety were also reviewed.

RESULTS

The IL-1β levels of subjects who underwent aneurysmal clipping were significantly lower in the acupuncture group (P = .02). TNF-α levels of subjects who underwent aneurysmal clipping at the seventh postoperative day were also significantly lower in the acupuncture group (P = .03). Six cases of fever of unknown origin were observed in the control group, while none were seen in the acupuncture group, revealing that the incidence of fever was significantly lower in the acupuncture group (P = .02). No adverse events occurred during the trial.

CONCLUSION

Acupuncture showed a possibility of alleviating inflammation by attenuating the levels of proinflammatory cytokines and significantly reduced the incidence of fever of unknown origin in patients after craniotomy. Acupuncture would be suitable as an adjunctive therapy to alleviate inflammation after craniotomy.

What interventions are performed in daily practice to prevent surgical site infections in neurosurgical patients? Findings from an explorative survey

Aim

The primary aim of the study was to describe the perioperative care ensured on a daily basis to prevent surgical site infection in Italian neurosurgeries; the secondary aim was to explore surgical site infections 30 days after the surgical procedures.

Methods

Patients cared for in 16 neurosurgical units who (a) were ≥18 years of age, (b) underwent neurosurgical procedures, and (c) were willing to participate in the study were taken into account.

Results

A total of 383 patients were included. A preoperative shower was performed in 332 cases (86.7%), shaving in 318 (83%) cases, and antibiotic prophylaxis was administered in 293 (76.5%) cases. Surgical site disinfection was performed mainly with povidone–iodine (344; 89.8%). A surgical site dressing was applied in 376 (98.2%) cases and was changed on average after 37.8h for shaved and 39h for non-shaved patients. Postoperative shampooing was performed only in 74 (19.3%) cases. Surgical site infection at 30 days occurred in three (0.8%) patients. Discussion and conclusions: Perioperative care aimed at preventing surgical site infections is variable across Italian neurosurgical units. More studies aimed at developing evidence capable of supporting decision-making processes in neurosurgery care are strongly recommended.

Antibacterial prophylaxis for gram-positive and gram-negative infections in cranial surgery: A meta-analysis

BACKGROUND

Perioperative antibiotic prophylaxis against gram positive and gram negative infections is considered standard of care in the perioperative management of patients undergoing cranial surgery. The antibiotic regimen which best reduces the risk of surgical site infections (SSIs) remains controversial.

OBJECTIVES

A systematic literature review and meta-analysis were conducted to examine the effect of various prophylactic antibiotics on infection incidence among patients undergoing cranial surgeries.

METHODS

A comprehensive search was conducted on Pubmed, EMBASE and Cochrane databases through October 2014 for studies that evaluated the efficacy of antibiotic prophylaxis among patients undergoing cranial surgeries. Pooled effect estimates using both fixed- and random-effect models were calculated.

RESULTS

Eight articles were included in the meta-analysis, with a combined total of 1655 cranial procedures. Among these, 74 cases of SSIs were reported after patients received a single antibiotic or a combination of 2 or more antibiotics (pooled incidence of SSIs=6.00%; 95% CI=4.80%, 7.50%; fixed-effects model; I²=73.7%; P-heterogeneity<0.01). Incidence of SSI was 1.00% (95% CI=0.40%, 2.60%) for non-MRSA gram-positive bacterial infections; 2.70% (95% CI=0.90%, 8.00%) for gram-negative bacterial infections; 6.00% (95% CI=4.50%, 7.80%) for gram negative, and non-MRSA gram-positive bacterial infections; and 11.3% (95% CI=7.20%, 17.4%) for gram negative and MRSA gram-positive bacterial infections. Subgroup analysis revealed an effect modification by drug class (P=0.05) and infection type (P-interaction=0.01). More specifically, lincosamides (2.70%; n=1 group), glycopeptides (2.80%; n=1), third generation cephalosporins (5.30%; n=2), antibiotics combination (4.90%; n=4), and penicillin-family antibiotics (5.90%, n=1) offered better coverage against infections than first generation cephalosporins (22.0%; n=2). A meta-regression analysis on study length was not significant (P=0.13). Random-effect models were not materially different form fixed-effects. No evidence of publication bias was found.

CONCLUSION

Lincosamides, glycopeptides, third generation cephalosporins, other combinations of prophylactic antibiotics, or penicillin-family antibiotics alone offer better coverage against SSIs than first generation cephalosporin among cranial surgery patients.

Enhanced recovery after surgery for oncological craniotomies

Enhanced recovery after surgery (ERAS) initiatives in the fields of gastrointestinal and pelvic surgery have contributed to improved postoperative functional status for patients and decreased length of stay. A similar comprehensive protocol is lacking for patients undergoing craniotomy for tumor resection. A literature search was performed using PubMed. These references were reviewed with a preference for recent high quality studies. Cohort and retrospective studies were also included if higher levels of evidence were lacking. A literature search was conducted for scalp blocks and minimally invasive craniotomies. Papers were scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria for evidence level and recommendation grade. Seventeen ERAS items were reviewed and recommendations made. The current body of evidence is insufficient to create a standardized protocol for craniotomy and tumor resection. However, this initial review of the literature supports pursuing future research initiatives that explore modalities to improve functional recovery and decrease length of stay in craniotomy patients.