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Kajal S, Mishra A, Gupta P, Kumar Kairo A. Duration of Antibiotic Prophylaxis for Cochlear Implantation: A Systematic Review. J Int Adv Otol 2022; 18:269-275. [PMID: 35608498 PMCID: PMC10682799 DOI: 10.5152/iao.2022.21454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2023] Open
Abstract
Antibiotic prophylaxis is commonly given to all patients undergoing cochlear implant surgery. However, currently, there is no consensus if pro- phylactic usage of antibiotics in cochlear implantation accords any benefit and if the duration of such use varies according to the surgeon's experience or institutional preference. A systematic review was conducted to gather evidence on ideal duration for antibiotic prophylaxis rec- ommended for patients undergoing cochlear implantation. We registered the protocol in the International Prospective Register of Systematic Reviews (CRD42021235079) and reported the systematic review following the Preferred Reporting Items for Systematic Reviews and Meta- Analysis statement. Of the 278 screened articles, 6 full-text original articles satisfied the inclusion criteria and were included. There were a total of 2081 participants in these 6 retrospective studies and all studies except 1 included both adult and pediatric populations. Antibiotic therapy was given as intervention, either as single dose or multiple doses, and compared with other group(s) receiving either no antibiotic prophylaxis or a different duration of prophylaxis. Three studies did not find any significant difference between infection rates when a different duration of antibiotic prophylaxis was given, while 2 studies found a single dose to be more efficacious, and yet another study concluded that a longer dura- tion of antibiotic prophylaxis was more beneficial. Based on the available data, the ideal duration of post-operative antibiotic therapy to be given after cochlear implant surgery could not be defined. However, administrating a single dose of intraoperative antibiotic seems to be the most consistent practice so far.
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Affiliation(s)
- Smile Kajal
- Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Archana Mishra
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Kumar Kairo
- Department of Otorhinolaryngology & Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
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García-Casallas JC, Blanco-Mejía JA, Fuentes- Barreiro YV, Arciniegas-Mayorga LC, Arias-Cepeda CD, Morales-Pardo BD. Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte. IATREIA 2019. [DOI: 10.17533/udea.iatreia.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.
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Simon TD, Schaffzin JK, Stevenson CB, Willebrand K, Parsek M, Hoffman LR. Cerebrospinal Fluid Shunt Infection: Emerging Paradigms in Pathogenesis that Affect Prevention and Treatment. J Pediatr 2019; 206:13-19. [PMID: 30528757 PMCID: PMC6389391 DOI: 10.1016/j.jpeds.2018.11.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/09/2018] [Accepted: 11/13/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington, United States,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, United States
| | - Joshua K. Schaffzin
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
| | - Charles B. Stevenson
- Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
| | - Kathryn Willebrand
- Department of Microbiology, University of Washington, Seattle, Washington, United States
| | - Matthew Parsek
- Department of Microbiology, University of Washington, Seattle, Washington, United States
| | - Lucas R. Hoffman
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington, United States,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington, United States,Department of Microbiology, University of Washington, Seattle, Washington, United States,Center for Infection and Prematurity Research, Seattle Children’s Research Institute, Seattle, Washington, United States
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Omrani O, O'Connor J, Hartley J, James G. Effect of introduction of a standardised peri-operative protocol on CSF shunt infection rate: a single-centre cohort study of 809 procedures. Childs Nerv Syst 2018; 34:2407-2414. [PMID: 30132097 PMCID: PMC6224013 DOI: 10.1007/s00381-018-3953-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/15/2018] [Indexed: 10/30/2022]
Abstract
PURPOSE Shunt infection is a major problem in paediatric neurosurgery. Our institution introduced a mandatory shunt protocol with the aim of reducing infection rate. METHODS A retrospective cohort study including consecutive patients undergoing permanent shunt operations (primary insertion and revision) across two study periods: 3 years immediately prior (2009-2012) and 3 years immediately after (2012-2015) protocol introduction. Absolute and relative risk reductions (ARR/RRR) and Chi-square statistical analysis was used alongside logistic regression, where any single factor with p ≤ 0.20 included in the multivariate model, producing an odds ratio (OR). RESULTS Eight hundred nine operations in 504 children were identified (442 pre-protocol, 367 post). Overall infection rate decreased from 5.43% (24/442) pre-protocol to 3.27% (12/367) post-protocol (ARR = 2.16%, RRR = 39.8%, NNT = 46.3, p = 0.138), which did not reach statistical significance. For primary shunt insertions, infection rate reduced from 3.63 to 2.55% (ARR = 1.08%, RRR = 29.8%, NNT = 92.6, p = 0.565), whilst for revisions, it reduced from 6.83 to 3.81% (ARR = 3.02%, RRR 44.2%, NNT = 33.1, p = 0.156). Multivariate logistic regression showed that surgeon experience was a statistically significant predictor of infection, whilst responsible pathogens and latency were similar across the pre- and post-protocol groups. CONCLUSION The protocol reduced overall infection rate in primary and revision shunt operations and we recommend paediatric units consider introducing a similar protocol for these procedures.
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Affiliation(s)
- Osama Omrani
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Jody O'Connor
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - John Hartley
- Department of Microbiology, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, UK.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
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Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, van de Beek D, Bleck TP, Garton HJL, Zunt JR. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis 2017; 64:e34-e65. [PMID: 28203777 DOI: 10.1093/cid/ciw861] [Citation(s) in RCA: 466] [Impact Index Per Article: 66.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/16/2016] [Indexed: 12/13/2022] Open
Abstract
The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.
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Affiliation(s)
- Allan R Tunkel
- Department of Internal Medicine-Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rodrigo Hasbun
- Department of Infectious Diseases, the University of Texas Health Science Center at Houston, Texas
| | - Adarsh Bhimraj
- Department of Infectious Diseases, Cleveland Clinic, Ohio
| | - Karin Byers
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pennsylvania
| | - Sheldon L Kaplan
- Department of Pediatrics-Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - W Michael Scheld
- Division of Infectious Diseases, University of Virginia, Charlottesville
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, The Netherlands
| | - Thomas P Bleck
- Departments of Neurological Sciences, Neurosurgery, Anesthesiology, and Medicine, Rush Medical College, Chicago, Illinois
| | - Hugh J L Garton
- Department of Neurological Surgery, University of Michigan, Ann Arbor; and
| | - Joseph R Zunt
- Departments of Neurology, Global Health, Medicine-Infectious Diseases, and Epidemiology, University of Washington, Seattle
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Moussa WMM, Mohamed MAA. Efficacy of postoperative antibiotic injection in and around ventriculoperitoneal shunt in reduction of shunt infection: A randomized controlled trial. Clin Neurol Neurosurg 2016; 143:144-9. [PMID: 26945767 DOI: 10.1016/j.clineuro.2016.02.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Infection is a common complication of ventriculoperitoneal (VP) shunt surgery. The incidence of shunt infection is still high despite routine administration of perioperative antibiotics. A lower incidence of shunt infection was observed when antibiotic-impregnated shunts (AIS) were used to treat hydrocephalus and a rapid cure was reported in cases of ventriculitis when antibiotics were injected into external ventricular drain (EVD). That is why we theorized that postoperative prophylactic injection of antibiotics in and around the shunt hardware would reduce the incidence of shunt infection. PATIENTS AND METHODS A randomized controlled clinical trial where 60 patients up to one year old, diagnosed with congenital hydrocephalus and submitted to VP shunt insertion, were randomly assigned to one of 3 groups. The treatment groups received the conventional perioperative antibiotics in addition to vancomycin and gentamicin injection in the reservoir and around the peritoneal catheter either once (group A) or twice (group B), while the control group (C) received only the conventional perioperative antibiotics. Cases were followed-up for up to 1 year. RESULTS The majority of patients were less than 1 month old. The follow-up period ranged from 2 to 12 months with a mean of 8.9 months. The mean duration of onset of infection after surgery was 30 days. Prematurity (p=0.00236), age less than one month (p<0.0001) and duration of surgery of 90 min or more (p<0.00001) were significant risk factors for postoperative shunt infection. Significantly more cases of shunt infection occurred within one month after surgery (p=0.021). The control group had significantly more cases of postoperative shunt infection than the treatment groups (p=0.0042). CONCLUSIONS In congenital hydrocephalus patients submitted to VP shunt insertion, injection of prophylactic vancomycin and gentamicin in and around the shunt hardware significantly reduced the incidence of postoperative shunt infection.
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Sarmey N, Kshettry VR, Shriver MF, Habboub G, Machado AG, Weil RJ. Evidence-based interventions to reduce shunt infections: a systematic review. Childs Nerv Syst 2015; 31:541-9. [PMID: 25686893 DOI: 10.1007/s00381-015-2637-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/03/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Cerebrospinal fluid shunt infection is associated with patient morbidity and high cost. We conducted a systematic review of the current evidence of comprehensive surgical protocols or individual interventions designed to reduce shunt infection incidence. METHODS A systematic review using PubMed and SCOPUS identified studies evaluating the effect of a particular intervention on shunt infection risk. Systemic prophylactic antibiotic or antibiotic-impregnated shunt efficacy studies were excluded. A total of 7429 articles were screened and 23 articles were included. RESULTS Eight studies evaluated the effect of comprehensive surgical protocols. Shunt infection was reduced in all studies (absolute risk reduction 2.2-12.3 %). Level of evidence was low (level 4 in seven studies) due to the use of historical controls. Compliance ranged from 24.6 to 74.5 %. Surgical scrub with antiseptic foam and omission of a 5 % chlorhexidine gluconate preoperative hair wash were both associated with increased shunt infection. Twelve studies evaluated the effect of a single intervention. Only antibiotic-impregnated suture, a no-shave policy, and double gloving with glove change prior to shunt handling, were associated with a significant reduction in shunt infection. In a hospital with high methicillin-resistant staphylococcus aureus (MRSA) prevalence, a randomized controlled trial found that perioperative vancomycin rather than cefazolin significantly reduced shunt infection rates. CONCLUSION Despite wide variation in compliance rates, the implementation of comprehensive surgical protocols reduced shunt infection in all published studies. Antibiotic-impregnated suture, a no-shave policy, double gloving with glove change prior to device manipulation, and 5 % chlorhexidine hair wash were associated with significant reductions in shunt infection.
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Affiliation(s)
- Nehaw Sarmey
- Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
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Nelson ET, Gross ME, Mone MC, Hansen HJ, Nelson EW, Scaife CL. A survey of American College of Surgery fellows evaluating their use of antibiotic prophylaxis in the placement of subcutaneously implanted central venous access ports. Am J Surg 2013; 206:1034-9; discussion 1039-40. [DOI: 10.1016/j.amjsurg.2013.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/19/2013] [Accepted: 07/19/2013] [Indexed: 12/22/2022]
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Abstract
Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.
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Affiliation(s)
- Katharina M Busl
- Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center, 1725 West Harrison Street, POB Suite 1121, Chicago, IL, 60612, USA,
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Wang X, Dong Y, Qi XQ, Li YM, Huang CG, Hou LJ. Clinical review: Efficacy of antimicrobial-impregnated catheters in external ventricular drainage - a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:234. [PMID: 23890254 PMCID: PMC4056565 DOI: 10.1186/cc12608] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To assess the efficacy of antimicrobial-impregnated catheters in preventing catheter-related infections during external ventricular drainage (EVD), we performed a meta-analysis and systematic review. We systematically searched Medline, Embase, and the Cochrane Library. All randomized controlled trials (RCTs) and nonrandomized prospective studies (NPSs) related to antimicrobial-impregnated EVD catheters were included. The primary outcome was the rate of cerebrospinal fluid infection (CFI). The secondary outcomes included the rate of time-dependent CFI and catheter bacterial colonization. We further performed subgroup analysis, meta-regression analysis, and microbial spectrum analysis. Four RCTs and four NPSs were included. The overall rate of CFIs was 3.6% in the antimicrobial-impregnated catheter group and 13.7% in the standard catheter group. The pooled data demonstrated that antimicrobial-impregnated catheters were superior to standard catheters in lowering the rate of CFIs (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.12 to 0.52, P <0.05). In survival analysis, the 20-day infection rate was significantly reduced with the use of antimicrobial-impregnated catheters (hazard ratio = 0.52, 95% CI = 0.29 to 0.95, P <0.05). Furthermore, a significantly decreased rate of catheter bacterial colonization was noticed for antimicrobial-impregnated catheters (OR = 0.37, 95% CI = 0.21 to 0.64, P <0.05). In subgroup analyses, although significant results remained for RCTs and NPSs, a subgroup difference was revealed (P <0.05). Compared with standard catheters, a significantly lower rate of CFIs was noticed for clindamycin/rifampin-impregnated catheters (OR = 0.27, 95% CI = 0.10 to 0.73, P <0.05) and for minocycline/rifampin-impregnated catheters (OR = 0.11, 95% CI = 0.06 to 0.21, P <0.05). However, no statistical significance was found when compared with silver-impregnated catheters (OR = 0.33, 95% CI = 0.07 to 1.69, P = 0.18). In microbial spectrum analysis, antimicrobial-impregnated catheters were shown to have a lower rate of Gram-positive bacterial infection, particularly the coagulase-negative Staphylococcus. In conclusion, the use of antimicrobial-impregnated EVD catheters could be beneficial for the prevention of CFI and catheter bacterial colonization. Although antibiotic-coated catheters seem to be effective, no sufficient evidence supports the efficacy of silver-impregnated catheters.
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Abstract
Central nervous system (CNS) infections—i.e., infections involving the brain (cerebrum and cerebellum), spinal cord, optic nerves, and their covering membranes—are medical emergencies that are associated with substantial morbidity, mortality, or long-term sequelae that may have catastrophic implications for the quality of life of affected individuals. Acute CNS infections that warrant neurointensive care (ICU) admission fall broadly into three categories—meningitis, encephalitis, and abscesses—and generally result from blood-borne spread of the respective microorganisms. Other causes of CNS infections include head trauma resulting in fractures at the base of the skull or the cribriform plate that can lead to an opening between the CNS and the sinuses, mastoid, the middle ear, or the nasopharynx. Extrinsic contamination of the CNS can occur intraoperatively during neurosurgical procedures. Also, implanted medical devices or adjunct hardware (e.g., shunts, ventriculostomies, or external drainage tubes) and congenital malformations (e.g., spina bifida or sinus tracts) can become colonized and serve as sources or foci of infection. Viruses, such as rabies, herpes simplex virus, or polioviruses, can spread to the CNS via intraneural pathways resulting in encephalitis. If infection occurs at sites (e.g., middle ear or mastoid) contiguous with the CNS, infection may spread directly into the CNS causing brain abscesses; alternatively, the organism may reach the CNS indirectly via venous drainage or the sheaths of cranial and spinal nerves. Abscesses also may become localized in the subdural or epidural spaces. Meningitis results if bacteria spread directly from an abscess to the subarachnoid space. CNS abscesses may be a result of pyogenic meningitis or from septic emboli associated with endocarditis, lung abscess, or other serious purulent infections. Breaches of the blood–brain barrier (BBB) can result in CNS infections. Causes of such breaches include damage (e.g., microhemorrhage or necrosis of surrounding tissue) to the BBB; mechanical obstruction of microvessels by parasitized red blood cells, leukocytes, or platelets; overproduction of cytokines that degrade tight junction proteins; or microbe-specific interactions with the BBB that facilitate transcellular passage of the microorganism. The microorganisms that cause CNS infections include a wide range of bacteria, mycobacteria, yeasts, fungi, viruses, spirochaetes (e.g., neurosyphilis), and parasites (e.g., cerebral malaria and strongyloidiasis). The clinical picture of the various infections can be nonspecific or characterized by distinct, recognizable clinical syndromes. At some juncture, individuals with severe acute CNS infections require critical care management that warrants neuro-ICU admission. The implications for CNS infections are serious and complex and include the increased human and material resources necessary to manage very sick patients, the difficulties in triaging patients with vague or mild symptoms, and ascertaining the precise cause and degree of CNS involvement at the time of admission to the neuro-ICU. This chapter addresses a wide range of severe CNS infections that are better managed in the neuro-ICU. Topics covered include the medical epidemiology of the respective CNS infection; discussions of the relevant neuroanatomy and blood supply (essential for understanding the pathogenesis of CNS infections) and pathophysiology; symptoms and signs; diagnostic procedures, including essential neuroimaging studies; therapeutic options, including empirical therapy where indicated; and the perennial issue of the utility and effectiveness of steroid therapy for certain CNS infections. Finally, therapeutic options and alternatives are discussed, including the choices of antimicrobial agents best able to cross the BBB, supportive therapy, and prognosis.
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Affiliation(s)
- A Joseph Layon
- Pulmonary and Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania USA
| | - Andrea Gabrielli
- Departments of Anesthesiology & Surgery, University of Florida College of Medicine, Gainesville, Florida USA
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Abstract
Abstract
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13
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Weber C, Jakola AS, Gulati S, Nygaard ØP, Solheim O. Evidence-based clinical management and utilization of new technology in European neurosurgery. Acta Neurochir (Wien) 2013; 155:747-54. [PMID: 23440373 DOI: 10.1007/s00701-013-1640-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/06/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evidence-based medicine (EBM) has become one of the pillars of modern patient care. However, neurosurgery has always been an experience-based and technology-driven discipline, and it remains unknown to which extent European neurosurgeons follow high-level evidence-based recommendations. METHODS We conducted a Web-based survey with a 15-item questionnaire about evidence-based clinical management and utilization of new technology among European neurosurgeons. Two different sum scores were calculated from the questions concerning clinical practice; evidence-based treatment score and new technology score. A high evidence-based treatment score means that more clinical conditions (i.e., study questions) were managed in compliance with the available highest levels of evidence from published clinical trials. A high new technology score reflects the use of a high number of modern tools in neurosurgical practice. RESULTS A total of 239 neurosurgeons from 30 different European countries answered the questionnaire. There were large variations among European neurosurgeons in providing evidence-based care and in utilization of various modern tools. There were significant regional differences in evidence-based treatment scores and modern technology scores with higher scores in northern and western Europe. High-volume institutions were not associated with better evidence-based treatment scores, but had significantly higher new technology scores. There were significantly higher new technology scores at university hospitals and a trend towards higher evidence-based treatment scores compared to other hospitals. CONCLUSIONS Clinical management in neurosurgery does not always comply with the best available evidence and there are large regional differences in clinical management and in utilization of various modern tools. The position of evidence-based medicine in European neurosurgery seems weak and this may be a threat to the quality of care.
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Scaife CL, Gross ME, Mone MC, Hansen HJ, Litz CL, Nelson ET, Anderson CJ, Wagner G, Gawlick U, Nelson EW. Antibiotic prophylaxis in the placement of totally implanted central venous access ports. Am J Surg 2010; 200:719-22; disussion 722-3. [DOI: 10.1016/j.amjsurg.2010.07.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 07/26/2010] [Accepted: 07/26/2010] [Indexed: 11/15/2022]
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Comparative effectiveness of medical interventions in adults versus children. J Pediatr 2010; 157:322-330.e17. [PMID: 20434730 DOI: 10.1016/j.jpeds.2010.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 01/15/2010] [Accepted: 02/09/2010] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To estimate the comparative effectiveness of medical interventions in adults versus children. STUDY DESIGN We identified from the Cochrane Database of Systematic Reviews (Issue 1, 2007) meta-analyses with data on at least 1 adult and 1 pediatric randomized trial with binary primary efficacy outcome. For each meta-analysis, we calculated the summary odds ratio of the adult trials and the pediatric trials, respectively; the relative odds ratio (ROR) of the adult versus pediatric odds ratios per meta-analysis; and the summary ROR across all meta-analyses. ROR <1 means that the experimental intervention is more unfavorable in children than adults. RESULTS Across 128 eligible meta-analyses (1051 adult and 343 pediatric trials), the summary ROR did not show a statistically significant difference between adults and children (0.96; 95% confidence intervals, 0.86 to 1.08). However, in all meta-analyses except for 1, the individual ROR's 95% confidence intervals could not exclude a relative difference in efficacy over 20%. In two-thirds, the relative difference in observed point estimates exceeded 50%. Nine statistically significant discrepancies were identified; 4 of them were also clinically important. CONCLUSIONS Treatment effects are on average similar in adults and children, but available evidence leaves large uncertainty about their relative efficacy. Clinically important discrepancies may occur.
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Zunt JR. Infections of the central nervous system in the neurosurgical patient. HANDBOOK OF CLINICAL NEUROLOGY 2010; 96:125-141. [PMID: 20109679 DOI: 10.1016/s0072-9752(09)96009-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Joseph R Zunt
- Department of Neurology, Harborview Medical Center, Seattle, WA 98104, USA.
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Meyer E, Schwab F, Pollitt A, Bettolo W, Schroeren-Boersch B, Trautmann M. Impact of a change in antibiotic prophylaxis on total antibiotic use in a surgical intensive care unit. Infection 2009; 38:19-24. [PMID: 19904488 DOI: 10.1007/s15010-009-9115-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 08/24/2009] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of reducing the length of antibiotic prophylaxis for cerebro spinal shunts on total antibiotic use and key resistant pathogens. METHODS In January 2004, the use of antibiotic prophylaxis was reduced to a single shot dose with cefuroxime in an intensive care unit (ICU). Prior to this intervention, prophylaxis with second-generation cephalosporins was administered during the entire period of external cerebro spinal fluid (CSF) drainage. The effect on the antibiotic use density (AD: DDD [defined daily doses] per 1,000 patient-days[pd]) was calculated prior to (January 2002-December 2003) and following implementation of the intervention(January 2004-December 2006) by segmented regression analysis of an interrupted time series. Resistance proportions(RP) and resistance densities (RD), defined as resistant pathogen/1,000 pd of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis or E. faecium, third-generation-resistant (3GC) Escherichia coli and Klebsiella pneumoniae, and imipenem-resistant Pseudomonus aeruginosa, were compared by the Fisher's exact test before and after the intervention. RESULTS Total antibiotic use by 147 DDD/1,000 pd decreased after the intervention when pre-operative prophylaxis was changed into single shot prophylaxis, from an estimated mean of 1,036 DDD/1,000 pd before the intervention to 887DDD/1,000 pd post-intervention. This decrease was primarily due to a significant reduction in the amount of cefuroxime used for prophylaxis. The reduction in total antibiotic consumption was sustainable, and it did not increase again during the next 36 months. The RR and RD of third-generation cephalosporin-resistant E. coli increased after January 2004, whereas the percentage of MRSA significantly decreased. CONCLUSION Change to single shot prophylaxis along with an ongoing antibiotic stewardship program resulted in a cut-back in total antibiotic use amounting to as much as 15%. It would therefore appear that targeting interventions aimed at reducing antibiotic prophylaxis in surgical ICUs may be very worthwhile.
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Affiliation(s)
- E Meyer
- Institute of Hygiene and Environmental Medicine, Charité UniversityMedicine, Berlin, Germany.
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Soffietti R, Akerley W, Jensen RL, Bischoff J, Regierer AC. The role of intra-cerebrospinal fluid treatment and prophylaxis in patients with solid tumors. Semin Oncol 2009; 36:S55-68. [PMID: 19660684 DOI: 10.1053/j.seminoncol.2009.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metastasis to the central nervous system (CNS), including neoplastic meningitis (NM), is a devastating complication of systemic cancer. With the improved survival of cancer patients, the incidence of CNS metastasis is rising, especially among those with breast or lung carcinoma. New therapies that effectively treat these primary tumors outside of the CNS have underscored the significance of CNS metastases; they have become a significant clinical issue and a therapeutic challenge. This review discusses clinical situations in which treatment or chemoprophylaxis of CNS metastases and NM from breast or lung cancer may play an important role. Potential clinical trials to assess these assumptions also will be proposed.
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Affiliation(s)
- Riccardo Soffietti
- Department of Neuroscience, University and San Giovanni Battista Hospital, Torino, Italy.
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Tacconelli E, Cataldo M, Albanese A, Tumbarello M, Arduini E, Spanu T, Fadda G, Anile C, Maira G, Federico G, Cauda R. Vancomycin versus cefazolin prophylaxis for cerebrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. J Hosp Infect 2008; 69:337-44. [DOI: 10.1016/j.jhin.2008.04.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 04/25/2008] [Indexed: 11/30/2022]
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Sampedro MF, Patel R. Infections associated with long-term prosthetic devices. Infect Dis Clin North Am 2008; 21:785-819, x. [PMID: 17826624 DOI: 10.1016/j.idc.2007.07.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The extensive and ever-increasing use of long-term prosthetic devices has improved quality of life and survival for many patients. Prosthetic device-related infection occurs infrequently but is associated with significant morbidity and mortality. Management is challenging, often requiring prolonged antimicrobial therapy and surgical intervention. Better understanding of the interaction between microorganisms, devices, and the host should improve the ability to manage device-related infections. This article reviews recent advances in the diagnosis and treatment of infections associated with indwelling medical devices, highlighting those associated with prosthetic joints, cerebrospinal fluid shunts, and prosthetic heart valves.
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Affiliation(s)
- Marta Fernandez Sampedro
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Pirotte BJM, Lubansu A, Bruneau M, Loqa C, Van Cutsem N, Brotchi J. Sterile surgical technique for shunt placement reduces the shunt infection rate in children: preliminary analysis of a prospective protocol in 115 consecutive procedures. Childs Nerv Syst 2007; 23:1251-61. [PMID: 17705062 DOI: 10.1007/s00381-007-0415-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate whether the rigid application of a sterile protocol for shunt placement was applicable on a routine basis and allowed the reduction of shunt infections (SI) in children. MATERIALS AND METHODS Since 2001, a rigid sterile protocol for shunt placement in children using neither antibiotic-impregnated catheters nor laminar airflow was prospectively applied at Erasme Hospital, Brussels, Belgium. For assessing the protocol efficacy before continuation, we preliminarily analyzed the results of the first 100 operated children (43 females, 57 males, 49 aged <12 months; 115 consecutive shunt placement/revision procedures). All procedures were performed by the same senior surgeon, one assistant, one circulating nurse, one anesthesiologist. The sterile protocol was rigidly imposed to these four staff members: uniformed surgical technique; limited implant and skin edge manipulation; minimized human circulation in the room; scheduling surgery as first morning operation; avoiding postoperative cerebrospinal fluid (CSF) leak; double gloving; procedures of less than 30-min duration; systemic antibiotics prophylaxis. We analyzed separately: (1) children carrying an increased risk of SI (n = 38) due to preoperative external ventricular drainage, CSF leak, meningitis, glucocorticoids, chemotherapy; (2) children aged <12 months; (3) procedures for shunt revision. RESULTS Errors in protocol application were recorded in 71/115 procedures. They were mainly done by non-surgical staff, decreased with time and were medically justified in some young children. Surprisingly, no SI occurred (follow-up, 4 to 70 months). One child developed an appendicitis with peritonitis (Streptococcus faecalis) after 6 months. No SI was found. After peritonitis was cured, shunt reinsertion was uneventful. CONCLUSION These preliminary results suggest that a uniform and drastic sterile surgical technique for shunt placement: (1) can be rigidly applied on a routine basis; (2) can lower the early SI rate below 1%; (3) might have a stronger impact to reduce SI than using antibiotic-impregnated catheters and optimizing the operative environment such as using laminar airflow and reducing the non-surgical staff. This last issue will be evaluated further in the present ongoing protocol.
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Affiliation(s)
- Benoit J M Pirotte
- Department of Neurosurgery, ERASME Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070 Brussels, Belgium.
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