Controversies in the prevention of neurosurgical infection

Efficacy of ultra-short single agent regimen antibiotic chemo-prophylaxis in reducing the risk of meningitis in patients undergoing endoscopic endonasal transsphenoidal surgery

OBJECTIVES

The study aims to evaluate the incidence of infectious complications (namely meningitis) within 30 days after endoscopic endonasal transspheinodal neurosurgery (EETS) in patients receiving an ultra-short peri-operative chemo-prophylaxis regimen with 2 doses of 1st generation cephalosporin or macrolide.

PATIENTS AND METHODS

We retrospectively analyzed the clinical records of 145 patients who received an ultra-short chemoprophylaxis with two doses of an antibiotic, given 30 min before and 8h after EETS, over a 30-month time-frame. Ninety-seven patients (66.89%) received endovenous cefazolin, a 1st generation cephalosporin, administered at a dosage of 1000 mg, and 48 patients (33.10%) with an history of allergy to various agents, received endovenous clarithromycin at a dosage of 500 mg.

RESULTS

No case of peri- and post-operative meningitis occurred in patients receiving the 2 doses of antibiotic. Only one patient (0.68%) developed cerebral fluid leakage on the 7th postoperative day, which required the switching to a broad-spectrum antibiotic prophylaxis for one week; this patient received the ultrashort prophylaxis with a macrolide. In addition, 7 patients (4.82%) developed minor infectious complications such as low-grade fever (3 cases, all of them receiving cefazolin), enlarged submandibular and cervical lymphnodes (3 cases, all of them receiving cefazolin), and upper and lower respiratory tract infection (1 case receiving clarithromycin). The cost of this prophylaxis regimen ranged from 7.76 Euro (cefazolin) to 39.54 Euro (clarithromycin).

CONCLUSIONS

This study suggested that an ultra-short single-antibiotic prophylaxis is a safe, cheap and effective regimen to prevent post-operative meningitis in patients undergoing EETS and who do not require lumbar drainage after surgery. In these patients also the rate of minor infective complications was acceptable when compared with the previous more expensive regimen based on 3rd generation cephalosporin plus aminoglycoside or alone, that could be suitable only for at-risk patients (e.g. smokers, cerebrospinal leak or Cushing's diseases).

Polymicrobial skull osteomyelitis: a rare complication of subdural hematoma evacuation

BACKGROUND

Osteomyelitis of the skull (SO) is a rare condition. The infection may complicate community-acquired sinusitis, otitis, or mastoiditis, in which case, the skull base is affected most commonly. The flora typically seen in these conditions, such as Streptococcus pneumoniae and Haemophilus influenzae, tends also to be responsible for the SO. Osteomyelitis also may follow neurosurgical procedures that breach the skull, in which case, the pathogens frequently are typical cutaneous flora such as Staphylococcus aureus or coagulase-negative staphylococci.

METHODS

A case report of post-neurosurgical SO and a review of the relevant English-language literature.

RESULTS

We report a delayed presentation of SO after craniotomy for the evacuation of a chronic subdural hematoma. Cranial tissue cultures grew Staphylococcus aureus, Corynebacterium spp., and Escherichia coli.

CONCLUSIONS

The isolation of Escherichia coli as an infecting organism in SO has been reported rarely and may reflect a unique pathogenesis.

Retrospective analysis of a new antibiotic chemoprophylaxis regimen in 170 patients undergoing endoscopic endonasal transsphenoidal surgery

BACKGROUND

The aim of this study is to evaluate the rate of infectious complications post endoscopic transspheinodal neurosurgery in patients receiving a new antibiotic chemoprophylaxis regimen.

METHODS

Clinical records of 170 patients who received prophylaxis with a third-generation cephalosporin plus aminoglycoside (160 cases) or alone (10 cases) were retrospectively analyzed. Twenty-eight patients (16.4%) had CSF leakage. The postsurgical follow-up ranged from 3 months to 4 years.

RESULTS

Of 170 patients, 2 (1.17%) developed infectious complications: 1 case of meningitis by Staphylococcus epidermidis and 1 case of sphenoid sinusitis (without microbiological diagnosis). In addition, asymptomatic sphenoid sinusitis was diagnosed in 2 other patients. The cost ranged from 22.50 to 33.34 euros/d.

CONCLUSIONS

The rate of infectious complications was very low in patients receiving prophylaxis with a third-generation cephalosporin plus aminoglycoside or alone; because of the broad-spectrum of antibiotics and their high cost, this regimen could be used in at-risk patients (eg, smokers, patients with cerebrospinal leak, or patients with Cushing diseases).

Hospital-acquired infection surveillance in a neurosurgical intensive care unit

A prospective study on hospital-acquired infection (HAI) was undertaken in the eight-bed neurosurgical intensive care unit (NSICU) of a teaching hospital in Rome, Italy. All patients admitted for >48 h between January 2002 and December 2004 were included. The infection control team collected the following data from all patients: demographic characteristics, patient origin, diagnosis, severity score, underlying diseases, invasive procedures, HAI, isolated micro-organisms and antibiotic susceptibilities. Overall, 323 patients were included in the study. Mean age was 55.5 years (range 17-91), and mean American Society of Anesthesiologists' score was 2.88. Seventy (21.7%) patients developed 132 NSICU HAIs: 43 pneumonias, 40 bloodstream infections (BSIs), 30 urinary tract infections (UTIs), 10 cases of meningitis associated with an external ventricular drain (EVD) and nine surgical site infections (SSIs). The SSI rate was high (5.6%), but a reduction was achieved during the three-year period. There were 7.2 bloodstream infection episodes per 1000 days of device exposure; 11.00 pneumonias per 1000 days of mechanical ventilation and 4.5 UTIs per 1,000 days of urinary catheterisation. Among patients with an EVD, the SSI relative risk was 11.3 [95% confidence intervals (CI) 4.2-30.6; P<0.01]. Sixty-one (18.9%) patients died. Logistic regression analysis showed that mortality was significantly associated with infection [odds ratio (OR)=2.28; 95%CI 1.11-4.71; P=0.02] and age (OR=1.04; 95%CI 1.01-1.06; P=0.002). Candida spp. were the leading cause of UTIs (40.0%) and the third most common cause of BSIs (12.7%). Antibiotic-resistant pathogens included meticillin-resistant staphylococci (77.5%), carbapenem-resistant Pseudomonas aeruginosa (36.4%), and extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (75.0%). Although the overall incidence of infection (21.7%) was within the range of published data, the associated mortality, the increasing severity of illness of patients, and the emergence of multi-drug-resistant organisms shows the need to improve infection control measures.

Non-shaved ventriculoperitoneal shunt in Thailand

The objective of this study was to determine whether non-shaved patients undergoing ventriculoperitoneal shunt operations would experience a significantly increased shunt infection rate as compared to shaved patients. Clinical trials of non-shaved scalp preparation were performed in ventriculoperitoneal shunt procedures at Songklanagarind Hospital from January 1994 to December 1999. Exclusion criteria were poor scalp condition, previous shunt procedures and immunocompromised hosts. Statistical analysis using univariate, multivariate and logistic regression was used. One hundred and nineteen patients were included in the study. Thirty-six cases were in the non-shaved group. Thirty-eight of 119 cases were less than one year of age and congenital hydrocephalus was the most common problem. The only notable risk factor for shunt infection was an operation lasting more than 59 min. The shunt infection rate in the non-shaved and shaved groups was 6.25% and 14.94%, respectively (p>0.05). In conclusion, leaving the hair intact for ventriculoperitoneal shunt surgery is safe and not associated with increased risk of shunt infection. The non-shaved method may encourage quicker restoration of the patients' self-image and facilitate their early return to normal life.

Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis

BACKGROUND

This prospective study aimed to determine the spectrum and the main risk factors of surgical site infection (SSI) after neurosurgical procedures in our clinic.

METHODS

Consecutive patients undergoing neurosurgery between November 1, 2001, and November 1, 2002, were recruited for the study. All patients were followed for a minimum of 2 weeks postoperatively and all SSIs were recorded. The complete medical records of each case were reviewed, and data on 14 possible risk factors were extracted. Statistical analyses were performed to identify the risk factors for SSIs.

RESULTS

A total of 31 postoperative SSIs were identified among 503 cases included in the study, with a resulting overall infection rate of 6.2%. The risk of SSI was increased by age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1; P = .039), operation type such as "shunt operations" (OR, 670.4; 95% CI, 2.6-171123.1; P = .021), presence of foreign body (OR, 141.0; 95% CI, 2.5-7925.9; P = .016), presence of diabetes mellitus (OR, 24.3; 95% CI, 2.1-284.9; P = .011), and intracranial pressure monitoring (OR, 4878.9; 95% CI, 23.8-1001229; P = .002). The predominantly isolated microorganisms in patients with SSIs were Staphylococcus aureus (22 [71.0%]), Acinetobacter baumanii (5 [16.1%]), and Staphylococcus epidermidis (4 [12.9%]).

CONCLUSIONS

SSIs remain an important problem in neurosurgery. Identification of the risk factors for SSI will help physicians to improve patient care and may decrease mortality, morbidity, and health care costs of neurosurgery patients.

L'infection postopératoire après craniotomie chez l'adulte

OBJECTIVE

The aim of this study was to determine the risk factors for postoperative infection after craniotomy, a threat for the vital prognosis, in order to define specific prevention measures.

METHOD AND PATIENTS

An open prospective study was made on all adult patients undergoing craniotomy and followed 30 days postoperatively. The infections were defined according to CDCA criteria. The parameters studied were: age, sex, ASA and Glasgow scores, neurosurgical history, the type, the moment and the surface of shaving, antibioprophylaxis, and the type and duration of surgery as well as its emergency level.

RESULTS

One hundred and seventy patients were included. Thirty presented with an infection (17.6%), nine with a skull infection, 13 with meningitis, three with empyema, and two with osteitis. The risk factors identified thanks to a univariate analysis were the emergency level of surgery (P < 0.01), duration of surgery >200 min, and duration of stay in ICU >72 h (P < 0.02).

Intraoperative antibiotic prophylaxis in clean spinal surgery: a retrospective analysis in a consecutive series of 973 cases

BACKGROUND

Antibiotic prophylaxis in spine surgery is still a debated question, involving medical, ethical, economic, and legal issues. The aim of our retrospective study was to evaluate the safety and effectiveness of an intraoperative protocol of antibiotic prophylaxis.

METHODS

During a 3-year period, 973 patients were consecutively operated on for clean spinal operations. Twenty-three percent of the cases involved the cervical spine and 77% the thoraco-lumbar spine; about 90% of patients were operated on for degenerative diseases and the remaining for traumatic lesions or tumors. Patients undergoing operations shorter than 120 minutes received a single-dose of IV ampicillin 1000 mg and sulbactam 500 mg (AS) at induction of anesthesia. In procedures longer than 120 minutes and/or requiring prosthetic materials, an IV single-dose of teicoplanin 400 mg was also administered at the same time. A second intraoperative dose of AS and teicoplanin was administered in operations longer than 4 hours (240 minutes after the first one) and in procedures in which blood loss exceeded 1500 mL. Postoperative prophylaxis has never been performed.

RESULTS

The only side effect was a cutaneous rash in 7 cases (0.7%), without any consequence. A wound infection was detected in 9 cases (<1%), all successfully treated with surgical toilette and specific antibiotic treatment. A lumbar discitis was detected in 4 out of 657 microdiscectomies (0.6%).

CONCLUSIONS

Even if this study has the weakness of the retrospective character, our intraoperative antibiotic prophylaxis protocol proved to be safe and efficacious. We hope that these preliminary results will be confirmed by larger prospectic trials.