The Role of Antibiotic Prophylaxis in Clean Neurosurgery

Study of the Practice of Surgical Antibiotic Prophylaxis Use for Elective Neurosurgical Cases in a Tertiary Hospital and Understanding the Rationale

BACKGROUND

This study aims to evaluate the adherence to surgical antibiotic prophylaxis (SAP) guidelines in elective neurosurgery and assess the impact on surgical site infection (SSI) rates in a tertiary teaching hospital in Malaysia.

METHOD

A retrospective review was conducted on patients who underwent elective neurosurgical procedures from January 1, 2021, to December 31, 2021, in a 1600-bed tertiary teaching hospital. The study assessed adherence to national and hospital SAP guidelines, focusing on the choice of antibiotic, dosage, timing, and duration. Additionally, a survey was conducted among neurosurgeons to evaluate their knowledge, attitudes, and practices regarding SAP.

RESULT

Out of 202 patients included, there was a 99% compliance rate with antibiotic choice and 69.8% with the antibiotic duration. The SSI rate was identified at 6.4%. The knowledge, attitudes, and practices survey highlighted a strong awareness of SAP guidelines among surgeons, albeit with variations in practice, particularly in antibiotic duration and choice of antibiotics.

CONCLUSIONS

While there is high adherence to the correct choice of antibiotic for SAP in elective neurosurgery, there are gaps in compliance with the recommended duration of antibiotic use. The study highlights the need for targeted interventions to improve adherence to SAP guidelines, which could potentially reduce the incidence of SSI in neurosurgery. Ongoing education and auditing are essential to optimize SAP practices and enhance patient outcomes in neurosurgery.

Glioma grade and post-neurosurgical meningitis risk

BACKGROUND

Post-neurosurgical meningitis (PNM) constitutes a grave complication associated with substantial morbidity and mortality. This study aimed to determine the risk factors predisposing patients to PNM following surgery for low- and high-grade gliomas.

METHODS

We conducted a retrospective analysis encompassing all patients who underwent glioma surgery involving craniotomy at Turku University Hospital, Turku, Finland, between 2011 and 2018. Inclusion criteria for PNM were defined as follows: (1) Positive cerebrospinal fluid (CSF) culture, (2) CSF leukocyte count ≥ 250 × 106/L with granulocyte percentage ≥ 50%, or (3) CSF lactate concentration ≥ 4 mmol/L, detected after glioma surgery. Glioma grades 3-4 were classified as high-grade (n = 261), while grades 1-2 were designated as low-grade (n = 84).

RESULTS

Among the 345 patients included in this study, PNM developed in 7% (n = 25) of cases. The median time interval between glioma surgery and diagnosis of PNM was 12 days. Positive CSF cultures were observed in 7 (28%) PNM cases, with identified pathogens encompassing Staphylococcus epidermidis (3), Staphylococcus aureus (2), Enterobacter cloacae (1), and Pseudomonas aeruginosa (1). The PNM group exhibited a higher incidence of reoperations (52% vs. 18%, p < 0.001) and revision surgery (40% vs. 6%, p < 0.001) in comparison to patients without PNM. Multivariable analysis revealed that reoperation (OR 2.63, 95% CI 1.04-6.67) and revision surgery (OR 7.08, 95% CI 2.55-19.70) were significantly associated with PNM, while glioma grade (high-grade vs. low-grade glioma, OR 0.81, 95% CI 0.30-2.22) showed no significant association.

CONCLUSIONS

The PNM rate following glioma surgery was 7%. Patients requiring reoperation and revision surgery were at elevated risk for PNM. Glioma grade did not exhibit a direct link with PNM; however, the presence of low-grade gliomas may indirectly heighten the PNM risk through an increased likelihood of future reoperations. These findings underscore the importance of meticulous post-operative care and infection prevention measures in glioma surgeries.

Dopaminergic Cell Replacement for Parkinson's Disease: Addressing the Intracranial Delivery Hurdle

Parkinson's disease (PD) is an increasingly prevalent neurological disorder, affecting more than 8.5 million individuals worldwide. α-Synucleinopathy in PD is considered to cause dopaminergic neuronal loss in the substantia nigra, resulting in characteristic motor dysfunction that is the target for current medical and surgical therapies. Standard treatment for PD has remained unchanged for several decades and does not alter disease progression. Furthermore, symptomatic therapies for PD are limited by issues surrounding long-term efficacy and side effects. Cell replacement therapy (CRT) presents an alternative approach that has the potential to restore striatal dopaminergic input and ameliorate debilitating motor symptoms in PD. Despite promising pre-clinical data, CRT has demonstrated mixed success clinically. Recent advances in graft biology have renewed interest in the field, resulting in several worldwide ongoing clinical trials. However, factors surrounding the effective neurosurgical delivery of cell grafts have remained under-studied, despite their significant potential to influence therapeutic outcomes. Here, we focus on the key neurosurgical factors to consider for the clinical translation of CRT. We review the instruments that have been used for cell graft delivery, highlighting current features and limitations, while discussing how future devices could address these challenges. Finally, we review other novel developments that may enhance graft accessibility, delivery, and efficacy. Challenges surrounding neurosurgical delivery may critically contribute to the success of CRT, so it is crucial that we address these issues to ensure that CRT does not falter at the final hurdle.

Wound Microbiota and Its Impact on Wound Healing

Wound healing is a complex process influenced by age, systemic conditions, and local factors. The wound microbiota's crucial role in this process is gaining recognition. This concise review outlines wound microbiota impacts on healing, emphasizing distinct phases like hemostasis, inflammation, and cell proliferation. Inflammatory responses, orchestrated by growth factors and cytokines, recruit neutrophils and monocytes to eliminate pathogens and debris. Notably, microbiota alterations relate to changes in wound healing dynamics. Commensal bacteria influence immune responses, keratinocyte growth, and blood vessel development. For instance, Staphylococcus epidermidis aids keratinocyte progression, while Staphylococcus aureus colonization impedes healing. Other bacteria like Group A Streptococcus spp. And Pseudomonas affect wound healing as well. Clinical applications of microbiota-based wound care are promising, with probiotics and specific bacteria like Acinetobacter baumannii aiding tissue repair through molecule secretion. Understanding microbiota influence on wound healing offers therapeutic avenues. Tailored approaches, including probiotics, prebiotics, and antibiotics, can manipulate the microbiota to enhance immune modulation, tissue repair, and inflammation control. Despite progress, critical questions linger. Determining the ideal microbiota composition for optimal wound healing, elucidating precise influence mechanisms, devising effective manipulation strategies, and comprehending the intricate interplay between the microbiota, host, and other factors require further exploration.

Length of preoperative hospital stay is the dominating risk factor for surgical site infection in neurosurgery: A cohort data-driven analysis

Background

The number of days of preoperative hospital stay (PHS) is a modifiable variable that has shown contradictory surgical site infection (SSI) risk factor results in neurosurgery. We sought to pinpoint the day of PHS length related with a marked increase of risk of SSI.

Methods

From a tertiary teaching hospital, January 2015-December 2017, prospectively collected nonpercutaneous neurosurgery procedures with standard antibiotic prophylaxis and 1-year follow-up were evaluated. SSI risk factors were assessed through multiple logistic regression models with different thresholds of PHS.

Results

A total of 1012 procedures were included in the study. Incidence of SSI was 4.4%. The median PHS was higher in those with SSI than in those without (1 day, interquartile range [IQR]: 7 vs. 0 days, IQR: 1, respectively, P = 0.002). By the amount of six days of PHS, this exposure risk past the threshold of significance for impact on wound infection (OR 2.8; CI 1.23-6.39, P = 0.014). Operative time past 4 h (OR 2.11; CI 1.12-3.98; P = 0.021), and in some models, previous surgery at same admission were also identified by multivariate analysis as increasing postoperative SSI risk.

Conclusion

The gradual increase of the SSI OR associated with longer PHS days was the highest risk factor of SSI in our cohort of patients. Studies directed to reduce this complication should consider the PHS.

Incidence and perioperative risk factors for surgical site infections in neurosurgery: prospective observational study

Background

Surgical site infections (SSI) represent a burden on the health care system especially in developing countries with significant morbidity and mortality. In Egypt, especially in our institution, there is no registry for the SSI rate or the contributing factors with no clear guidelines regarding the regimen of perioperative antibiotic prophylaxis. Our study was conducted to assess the local practice and to calculate the rate and risk factors of SSI.

Patients and methods

A prospective registry was established at the Neurosurgery Department, Demerdash teaching hospital Ain Shams University, Cairo, Egypt. All patients who underwent elective neurosurgical procedures were included in this study. Trauma patients were excluded. Patients were followed-up for incident SSI for 1 month postoperatively. SSIs were identified based on CDC criteria and a standardized data collection form predictor variables including patient characteristics, preoperative, intraoperative, and postoperative factors along with the pattern of antimicrobial prophylaxis.

Results

The study included 248 patients with 1-month postoperative follow-up. An SSI rate of 19% was recorded being mainly in patients below 10 years of age. Postoperative CSF leak was noticed to be the most significant risk factor of SSI in our study (p value < 0.01). Sixty five percent of culture results showed infection with gram-negative bacilli with the predominance of Acinetobacter.

Conclusion

Prolonged use of perioperative antibiotics does not seem to have an added benefit in SSI prevention. Tailoring of the used antibiotic regimen is highly recommended according to the latest antimicrobial prophylaxis guidelines and the local culture and sensitivity results.

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.

Role of topical vancomycin in reduction of postoperative infections in head trauma patients: A developing country experience

BACKGROUND

Postoperative cranial wound infections are a major cause of morbidity, mortality, and financial burden, especially in developing countries.

METHODS

We prospectively studied 86 patients in a randomized trial; 39 patients received one gram of topical vancomycin powder in the subgaleal space while 47 matched control patients did not. Both groups received identical intraoperative and post-operative care. The primary outcome variable was the postoperative wound infections rate factored by cohort. Secondary outcomes were the timing of infection and the rate of adverse events.

RESULTS

Adding topical vancomycin was associated with a significantly lower rate of infection than the standard of care alone (2.6% [1/39] vs. 14.9% [7/47], P =.004). No adverse reactions occurred.

CONCLUSION

Topical vancomycin is safe, and effective in the prevention of surgical site infections following craniotomy. These findings have broad consequences for neurosurgery practice, especially in developing countries with high incidence of head trauma.

Discitis Following Radiofrequency Nucleoplasty: A Case Report

Introduction

Radiofrequency nucleoplasty is a minimally invasive procedure to treat chronic low back pain, especially mild degenerative disc diseases. Discitis after radiofrequency nucleoplasty is a rare case.

Case Presentation

A 62-year-old male patient with a chief complaint of 10 years low back pain, gradually worsening for the last two years, a history of hypertension, chronic kidney disease, and routine dialysis twice a week, referred to the center. He underwent a lumbar medial branch block using radiofrequency and radiofrequency nucleoplasty procedure of lumbar 4-5 (L4-L5). Three weeks after the intervention, he could not move his legs, associated with urinary and fecal incontinence. MRI (magnetic resonance imaging) of the lumbar spine was performed, and the results indicated hyperintensity in L4-L5, suspicious of discitis. Laminectomy at L4 and L5 was performed. Eight months after surgery, the patient could feel and lift legs, and urinary and fecal incontinence was also controlled.

Conclusions

Early diagnosis of discitis is critical and challenging. Delay in diagnosis may lead to treatment delay and the development of neurological deficits. Comprehensive treatment with bed rest, antimicrobial therapy, and sensible application of timely surgery are essentials to an optimal outcome.

Healthcare-Associated Infections in Subjects With Severe Acquired Brain Injury: The Effect of Microbial Colonization on the Functional Outcome. Data From a Multicenter Observational Study

Background: Hospital-acquired infections (HAIs) and microbial colonization are a worldwide serious threat for human health. Neurological patients with infections who undergo rehabilitation have a significantly poor recovery. The effect of microbial colonization on the functional outcome in severe acquired brain injury (sABI) subjects is still unclear. Aim: The aim of this multicenter observational study was to describe the clinical impact of HAIs and colonization on the functional outcome of sABI subjects admitted to inpatient neurorehabilitation. Methods: Patients were assigned to three groups: infected (INF), not infected (noINF), and colonized (COL). The Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale, Disability Rating Scale, and modified Barthel Index (mBI) assessments were performed both at admission and discharge. Results: Two hundred sixty-five (92 female/173 male) patients were enrolled: 134 were assigned to INF, 63 to COL, and 68 to noINF. In the INF group, 231 culture specimens were found positive for bloodstream (44.2%), respiratory tract (25.5%), urinary tract (18.6%), gastrointestinal tract (8.3%), skin (3%), and cerebrospinal fluid (0.4%) infections. After rehabilitation, all groups showed a significant improvement in all assessment tests, except for the noINF group that did not show any improvement in GCS. Both noINF and COL groups showed a significantly higher gain in mBI than the INF group (p = 0.000). The COL group showed a significantly higher gain than the noINF group in GCS (p = 0.001). A significantly lower improvement was detected in the INF group than the COL and noINF groups. The rate of patients who needed functional isolation was higher in the INF group than the COL group. Length of stay (LOS) (in days) was 56 ± 50.7, 88.3 ± 55, and 101.3 ± 73.6 for noINF, INF, and COL groups, respectively. The number of deaths in the INF group was significantly higher (24.6%) than the noINF group (7.4%) (p = 0.005) and comparable to the COL group (19%). Conclusion: Colonized sABI patients obtained a similar functional outcome to that of subjects who had no infections, even if they needed a significantly higher LOS.

Postoperative empyema following chronic subdural hematoma surgery: Clinically based medicine

INTRODUCTION

Subdural empyema (SDE) is a rare complication of chronic subdural hematoma (CSDH) surgery. We introduced antibiotic prophylaxis (AP) for this procedure in 2014 following a morbidity-mortality conference (MMC) in our department. We report the results of retrospective data analysis to assess the effect of systematic AP and to identify risk factors for SDE.

MATERIAL AND METHODS

Two hundred eight patients were recruited between January 2013 and December 2015; 5 were excluded for incomplete data: 107 without and 96 with AP (n=203). SDE was confirmed by clinical examination, imaging and bacteriological analysis. Comparisons between AP-(no cefuroxime) and AP+ (cefuroxime) groups were made with Chi² test and Student's t-test.

RESULTS

One empyema was found in each group, indicating that AP had no effect (P=1). The only criterion associated with SDE for these two patients was a greater number of reoperations for CSDH recurrence (P=0.013).

DISCUSSION

The incidence of postoperative empyema was 1%, similar to the range of 0.2%-2.1% reported in the literature. This rare incidence explains why we found no significant effect of AP. The medical decision taken at the MMC did not help to reduce the rate of postoperative SDE. MMCs can help to define factors associated with adverse surgical events and identify opportunities for improvement.

CONCLUSION

AP, introduced after an MMC, did not impact SDE rates. In practice, AP should be required only in case of reoperation for CSDH recurrence. However, we still continue to use AP following the MMC considering different parameters discussed in the manuscript.

Gentamicin loading of calcium phosphate implants: implications for cranioplasty

Background

Surgical site infections (SSI) are a significant risk in cranioplasty, with reported rates of around 8–9%. The most common bacteria associated with these nosocomial infections are of the Staphylococcus species, which have the ability to form biofilm. The possibility to deliver antibiotics, such as gentamicin, locally rather than systemically could potentially lower the early postoperative SSI. Various antibiotic dosages are being applied clinically, without any true consensus on the effectiveness.

Methods

Drug release from calcium phosphate (CaP), polyetheretherketone (PEEK), and titanium (Ti) samples was evaluated. Microbiological studies with Staphylococcus aureus (SA) and Staphylococcus epidermidis (SE) including strains from clinical infection were used to establish clinically relevant concentrations.

Results

The CaP samples were able to retain and release gentamicin overtime, whereas the Ti and PEEK samples did not show any drug uptake or release. A gentamicin loading concentration of 400 μg/ml was shown to be effective in in vitro microbiological studies with both SA and SE.

Conclusions

Out of the three materials studied, only CaP could be loaded with gentamicin. An initial loading concentration of 400 μg/ml appears to establish an effective gentamicin concentration, possibly translating into a clinical benefit in cranioplasty.

Risk factors for surgical site infections in neurosurgery

INTRODUCTION

Surgical site infections (SSIs) are of profound significance in neurosurgical departments, resulting in high morbidity and mortality. There are limited public data regarding the incidence of SSIs in neurosurgery. The aim of this study was to determine the rate of SSIs (particularly those requiring reoperation) over a seven-year period and identify factors leading to an increased risk.

METHODS

An age matched retrospective analysis was undertaken of a series of 16,513 patients at a single centre. All patients who required reoperation for suspected SSIs within a 7-year period were identified. Exclusion criteria comprised absence of infective material intraoperatively and patients presenting with primary infections. Clinical notes were reviewed to confirm presence or absence of suspected risk factors.

RESULTS

Of the 16,513 patients in the study, 1.20% required at least one further operation to treat a SSI. Wound leak (odds ratio [OR]: 27.41), dexamethasone use (OR: 3.55), instrumentation (OR: 2.74) and operative duration >180 minutes (OR: 1.85) were statistically significant risk factors for reoperation.

CONCLUSIONS

This is the first UK study of such a duration that has documented a SSI reoperation rate in a cohort of this size. Various risk factors are associated with the development of SSIs, making it essential to have robust auditing and monitoring of high risk patients to ensure excellent standards of healthcare. Departmental and public registers to record all SSIs may be beneficial, particularly for those treated solely by general practitioners, allowing units to address potential risk factors prior to surgical intervention.

Surgical site infection in elective clean and clean-contaminated surgeries in developing countries

BACKGROUND

Surgical site infection (SSI) is both the most frequently studied healthcare-associated infection and the most common healthcare-associated infection in the developing world. A systematic review and meta-analysis was conducted to evaluate the relative size of this burden and to estimate the prevalence of SSI in clean and clean-contaminated surgeries in a large sample of countries in the developing world.

METHODS

A systematic search of the MEDLINE/PubMed, Scopus, and LILACS databases was conducted to identify studies providing the prevalence of SSI in elective clean and clean-contaminated surgeries in 39 countries or regions around the world. Data of interest were limited to publications from January 2000 to December 2017. Studies with information on the number of cases of SSI and number of total elective clean and clean-contaminated surgeries during the same period were included in this evaluation. Studies lacking clear definition of the total number of exposed patients were excluded.

RESULTS

Based on the combined data from the 99 articles evaluated in this analysis, the overall prevalence of SSI in elective clean and clean-contaminated surgeries was estimated to be 6% (95% confidence interval (CI) 5-7%). This increased to 15% (95% CI 6-27%) when considering only those reports with post-discharge surveillance data. The overall prevalence of SSI in Africa/Middle East, Latin America, Asia, and China was 10% (95% CI 6-15%), 7% (95% CI 5-10%), 4% (95% CI 4-5%), and 4% (95% CI 2-6%), respectively. Significant variability in the data was confirmed by both the funnel plot and the Egger test (p=0.008).

CONCLUSIONS

Although the data are variable, it is clear that the incidence of SSI in the developing world is higher than that in the developed world.

Our experience with using a uniform prophylactic protocol in neurosurgery: surgical-site infection did not occur in 272 operations

PURPOSE

Surgical site infection (SSI) is a source of concern in any surgical procedure. Although studies with high numbers of patients are available, most of these studies were performed by different surgeons and the exact anti-SSI protocol is not mentioned or is not homogeneous in all patients.

MATERIALS AND METHODS

We present the results of 272 cases where SSI was successfully prevented in our neurosurgical units and in this study we explain our institutional protocol for achieving this positive result. We included all neurosurgical procedures in our two centers that needed an operating room, undertaken between 9 November 2015 and 6 December 2016, retrospectively. Then we compare our results with the existing literature.

RESULTS

We performed 272 neurosurgical procedures on 245 patients. 155 patients were male and 90 were female. We re-operated on 24 patients and 3 of them operated on three times in each instance case and others were operated on twice. The patient's ages ranged from 2 to 86years with the mean being 42.39 ± 19 years. The cranial site of surgery was more common (129 procedures, 47.4%) and overall 118 operations (43.4%) were accompanied with a prosthetic device placement. We performed 96 emergency procedures. The mean hospitalization time was 6.19 ± 6.77 days. We followed all patients for at least six months. There were no reports of SSI in our neurosurgical units.

CONCLUSION

With a fixed protocol of antisepsis, hand protection and prophylactic antibiotics, there were achieved good results. We recommend the current protocol as an effective measure in the control of infection in the neurosurgical ward. However, further studies are needed with more patients and a stronger study design.