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Azad MA, Patel R. Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections. Clin Microbiol Rev 2024; 37:e0010423. [PMID: 38506553 PMCID: PMC11237642 DOI: 10.1128/cmr.00104-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.
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Affiliation(s)
- Marisa Ann Azad
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robin Patel
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Magni F, Al-Omari A, Vardanyan R, Rad AA, Honeyman S, Boukas A. An update on a persisting challenge: A systematic review and meta-analysis of the risk factors for surgical site infection post craniotomy. Am J Infect Control 2024; 52:650-658. [PMID: 37989412 DOI: 10.1016/j.ajic.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) postcraniotomy continue to impose a significant burden on health care systems and patient outcomes. It is, therefore, important to understand their risk factors in order to promote effective preventative measures. This meta-analysis aims to provide a comprehensive, up-to-date analysis of the risk factors associated with SSIs in neurosurgical procedures. METHODS A systematic review was conducted as per preferred reporting items for systematic reviews and meta-analysis guidelines to explore existing primary evidence on the risk factors for SSIs postcraniotomy. A comprehensive search of MEDLINE, EMBASE, and Pubmed was performed from database inception up to June 2023. 43 studies were included in the meta-analysis, encompassing a total of 68,881 patients. RESULTS The strongest predictor for SSIs was found to be cerebrospinal fluid (CSF) leak (OR: 8.91, CI: 4.30-18.44). Other significant factors included infratentorial surgery (OR: 0.43, CI: 0.31-0.61), emergency surgery (OR: 1.41, CI: 1.05-1.91), reintervention (OR: 3.19, CI: 1.77-5.75), prolonged operative time (mean difference: 33.25; CI: 18.83-47.67), hospital length of stay (mean difference: 0.60; CI: 0.23-0.98) and intracranial pressure monitor (ICPM) insertion (OR: 1.81; CI: 1.06-3.11). Contrarily, sex, body mass index (BMI), diabetes, antibiotic prophylaxis, immunosuppressive agents, trauma, use of artificial implants did not demonstrate statistical significance. CONCLUSIONS This meta-analysis provides an up-to-date and comprehensive evaluation of risk factors for SSIs postcraniotomy. It emphasizes the need for preventive strategies, particularly against CSF leaks, and calls for further research to elucidate the intricate relationships between these factors.
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Affiliation(s)
- Francesco Magni
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.
| | - Aws Al-Omari
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Robert Vardanyan
- Department of Neurosurgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Arian A Rad
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Susan Honeyman
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Alexandros Boukas
- Department of Neurosurgery, Oxford University Hospital NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Liu H, Yang H, Guo X, Bai Y, SiRi G. Clinical benefits of therapeutic drug monitoring of vancomycin therapy in patients with postoperative intracerebral hemorrhage: a retrospective cohort study. Eur J Hosp Pharm 2024; 31:240-246. [PMID: 36207132 DOI: 10.1136/ejhpharm-2022-003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate the clinical efficacy and safety of conducting therapeutic drug monitoring (TDM) of vancomycin in patients with postoperative intracerebral haemorrhage. METHODS We conducted a retrospective analysis of 435 patients who experienced postoperative cerebral haemorrhage and were treated with vancomycin in the Department of Neurosurgery of Inner Mongolia Autonomous Region People's Hospital from January 2017 to December 2021. Patients were then matched using the propensity score matching method in a ratio of 1:1. Ninety-two pairs of cases were successfully matched, and the data before and after performing vancomycin TDM were analysed. RESULTS After PSM, the baseline data of the two groups were balanced. There were no significant differences in the 14-day mortality and length of hospital stay (p>0.05) between the two groups. Compared with the non-TDM group, the TDM group had a higher proportion of patients with normal white blood cells (83.7% vs 56.5%, p=0.000), neutrophil count (57.6% vs 25.0%, p=0.000) and attaining desirable reductions of 80% in procalcitonin (65.2% vs 10.9%, p=0.000) and C-reactive protein (78.3% vs 41.3%, p=0.000) levels. At US$15.82 per additional TDM, TDM significantly promoted patient outcomes, as seen in improvements in the proportion of patients attaining desirable levels of white blood cells, neutrophil count, procalcitonin and C-reactive protein. CONCLUSIONS Vancomycin TDM is a safe and effective approach for the treatment of patients with postoperative intracerebral haemorrhage. The empirical use of TDM of vancomycin significantly improved normal values of white blood cells and neutrophil count, achieved desirable reductions of 80% in procalcitonin and C-reactive protein, and reduced nephrotoxicity in patients with postoperative intracerebral haemorrhage.
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Affiliation(s)
- Huanhuan Liu
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
- Department of Pharmacy, Baotou Medical College, Baotou, Inner Mongolia, China
| | - Hongxin Yang
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Xiaobin Guo
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Yingchun Bai
- Department of Pharmacy, Baotou Medical College, Baotou, Inner Mongolia, China
| | - Guleng SiRi
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
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Kilinc F, Setzer M, Behmanesh B, Jussen D, Gessler F, Bayerl S, Kempf VAJ, Kessel J, Czabanka M, Prinz V. Effectiveness of outpatient parenteral antimicrobial therapy (OPAT) for patients with cranial infection. Front Med (Lausanne) 2023; 10:1202969. [PMID: 37942421 PMCID: PMC10628042 DOI: 10.3389/fmed.2023.1202969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023] Open
Abstract
Objective Outpatient parenteral antimicrobial therapy (OPAT) is a well-established and cost-effective method for improving the efficient use of healthcare resources. However, only a few centres in Germany perform it. Here we analysed OPAT for the treatment of patients with cranial infections in our neurosurgical department. Methods This retrospective study analysed patients with cranial infections and the need for intravenous (i.v.) antimicrobial treatment between 2018 and 2021.All diagnosed intracranial infections were defined into two infection categories such as long-term antimicrobial treatment and short-term antimicrobial treatment. All included patients were discharged with a peripherally inserted central catheter (PICC) line. Prior to discharge, all patients received training in the safe administration of their medications via the PICC line. The duration of OPAT and the rate of readmission after OPAT were analysed. Results We identified a total of 45 patients treated with OPAT for cranial infections. Intradural involvement was present in 40 cases (88.9%). The average length of hospital stay for this cohort after surgical treatment was 45 ± 15 days. 5 patients were treated for soft tissue/skin infection. Surgery was not required in this cohort. The mean hospital stay for this cohort was 8 ± 6 days. Gram-positive organisms were isolated in most cases (53.3%). The most common pathogens were Staphylococcus aureus followed by other Staphylococcus species. For all included patients, OPAT was performed after discharge for an average of 43.1 ± 14 days. There were five cases of readmission due to treatment failure. No serious adverse events or complications of OPAT were observed. Conclusion OPAT enables better patient-centred healthcare close to home. The length of hospital stay can be reduced and adverse events due to prolonged hospitalisation can be avoided.
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Affiliation(s)
- Fatma Kilinc
- Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany
| | - Matthias Setzer
- Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Daniel Jussen
- Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Simon Bayerl
- Department of Neurosurgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Volkhard A. J. Kempf
- Institute for Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
- University Center of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
- University Center of Competence for Infection Control of the State of Hesse, Frankfurt am Main, Germany
| | - Johanna Kessel
- University Center of Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Medicine, Infectious Diseases Unit, Goethe University Hospital, Frankfurt am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany
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Kulikov A, Krovko Y, Zagidullin T, Ershova O, Bilotta F. Association of Preoperative Glycated Hemoglobin and Early Postoperative Infections After Elective Craniotomy: A Retrospective Cohort Study. World Neurosurg 2023; 175:e505-e510. [PMID: 37028477 DOI: 10.1016/j.wneu.2023.03.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The prognostic value of preoperative glycated hemoglobin (HbA1c) testing is controversial. The available evidence on the role of preoperative HbA1c in predicting postoperative complications after different surgical procedures has been conflicting. The primary aim of our retrospective observational cohort study was to assess the association between preoperative HbA1c and postoperative infections after elective craniotomy. METHODS We extracted and analyzed data from an internal hospital database on 4564 patients who underwent neurosurgical intervention from January 2017 to May 2022. The primary outcome measure of the present study was infections established in the first week after surgery using the Centers for Disease Control and Prevention criteria. The records were stratified by the HbA1c values and intervention types. RESULTS For patients who had undergone brain tumor removal with a preoperative HbA1c ≥6.5%, the odds of early postoperative infections were increased (odds ratio, 2.08; 95% confidence interval, 1.16-3.72; P = 0.01). We found no association between HbA1c and early postoperative infections for patients who had undergone elective cerebrovascular intervention, cranioplasty, or a minimally invasive procedure. After adjusting for age and gender, the threshold for significant infection risk for neuro-oncological patients increased with an HbA1c ≥7.5% (adjusted odds ratio, 2.97; 95% confidence interval, 1.37-6.45; P = 0.0058). CONCLUSIONS For patients undergoing elective intracranial surgery for brain tumor removal, a preoperative HbA1c ≥7.5% is associated with a higher infection rate within the first postoperative week. Future prospective studies are required to assess the prognostic value of this association for clinical decision-making.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia.
| | - Yulia Krovko
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Timur Zagidullin
- Laboratory of Biomedical Informatics and Artificial Intelligence, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Olga Ershova
- Department of Epidemiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Italy
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Zhao A, Sun J, Liu Y. Understanding bacterial biofilms: From definition to treatment strategies. Front Cell Infect Microbiol 2023; 13:1137947. [PMID: 37091673 PMCID: PMC10117668 DOI: 10.3389/fcimb.2023.1137947] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/09/2023] [Indexed: 04/08/2023] Open
Abstract
Bacterial biofilms are complex microbial communities encased in extracellular polymeric substances. Their formation is a multi-step process. Biofilms are a significant problem in treating bacterial infections and are one of the main reasons for the persistence of infections. They can exhibit increased resistance to classical antibiotics and cause disease through device-related and non-device (tissue) -associated infections, posing a severe threat to global health issues. Therefore, early detection and search for new and alternative treatments are essential for treating and suppressing biofilm-associated infections. In this paper, we systematically reviewed the formation of bacterial biofilms, associated infections, detection methods, and potential treatment strategies, aiming to provide researchers with the latest progress in the detection and treatment of bacterial biofilms.
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Affiliation(s)
- Ailing Zhao
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| | - Jiazheng Sun
- Department of Vasculocardiology, Jinzhou Medical University, Jinzhou, Liaoning, China
| | - Yipin Liu
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
- *Correspondence: Yipin Liu,
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Zheng G, Wang S, Lv H, Zhang G. Nomogram Analysis of Clinical Characteristics and Mortality Risk Factor of Non-Fermentative Gram-Negative Bacteria-Induced Post-Neurosurgical Meningitis. Infect Drug Resist 2022; 15:6379-6389. [PMID: 36345538 PMCID: PMC9636862 DOI: 10.2147/idr.s385502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022] Open
Abstract
Objective To explore the clinical characteristics of post-neurosurgical meningitis (PNM) patients infected with nonfermenting Gram-negative bacilli (NFGNB) and to evaluate the related mortality risk factors. Methods A cohort analysis of PNM patients infected with NFGNB in Beijing Tiantan Hospital and Capital Medical University from 2012.1 to 2020.12. The microbial distribution, antimicrobial sensitivity and genotypes were tested, and potential mortality risk factors were evaluated using Mann–Whitney U or chi-squared tests. Independent risk factors for mortality were established by constructing a logistic model. Results A total of 2940 PNM patients were enrolled in this study, of whom 207 (17.1%) were infected with NFGNB. Among these patients, 29 died of NFGNB meningitis, with an overall mortality rate of 14.0%. The top three NFGNBs were Acinetobacter baumannii (105 cases, 50.7%), Pseudomonas aeruginosa (29 cases, 14.0%) and Acinetobacter lwoffii (20 cases, 9.7%). Nomogram analysis revealed that hypertension (OR 4.551, 95% CI: 1.464–14.154, P = 0.009), external ventricular drainage (EVD) (OR 3.944, 95% CI: 1.286–12.095, P = 0.016), and assisted mechanical ventilator (AMV) (OR 6.192, 95% CI: 1.737–22.081, P = 0.005) were independent risk factors for mortality. In addition, antibiotic prophylaxis was shown to play a vital role in NFGNB-induced PNM therapy. Conclusion PNM patients infected with NFGNB have a high mortality rate. Hypertension, EVD and AMV were independent mortality risk factors, and clinical attention should be paid to their prevention and treatment.
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Affiliation(s)
- Guanghui Zheng
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
| | - Siqi Wang
- School of clinical laboratory diagnostics, Capital Medical University, Beijing, 100076, People’s Republic of China
| | - Hong Lv
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
| | - Guojun Zhang
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
- Correspondence: Guojun Zhang, Laboratory of Beijing Tiantan Hospital, Capital Medical University, NO. 119 Nansihuan West Road, Fengtai District, Beijing, People’s Republic of China, Tel +86 15811219411, Email
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Kulikov A, Krovko Y, Nikitin A, Shmigelsky A, Zagidullin T, Ershova O, Gadzhieva O, Bilotta F. Severe Intraoperative Hyperglycemia and Infectious Complications After Elective Brain Neurosurgical Procedures: Prospective Observational Study. Anesth Analg 2022; 135:1082-1088. [PMID: 35051950 DOI: 10.1213/ane.0000000000005912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Postoperative infections after brain surgery are a serious complication potentially worsening the outcome of surgical treatment. Severe intraoperative hyperglycemia (SIH) contributes to both infectious and noninfectious postoperative complications. However, there are a lack of data on the incidence of SIH in patients undergoing elective neurosurgical brain procedures and its association with the risk of postoperative infections. METHODS A total of 514 patients were prospectively enrolled in this single-center observational cohort clinical study to assess the incidence of SIH (blood glucose concentration [BGC] ≥180 mg/dL) in adult patients undergoing elective brain neurosurgical procedures and its association with postoperative infections. Both nondiabetic and diabetic patients were included in the study. BGC was determined by whole-blood analyses taken at the beginning and at the end of the surgery. Diagnosis of infection (wound, pulmonary, blood stream, urinary tract infection, or central nervous system infection) was established according to US Centers for Disease Control and Prevention (CDC) criteria within the first postoperative week. RESULTS SIH was recorded in at least 1 blood sample in 23 patients (4.5%). Infectious complications within the first postoperative week were diagnosed in 40 patients (7.8%). Five of 23 patients (22%) with SIH had postoperative infections, compared with 35 of 491 patients (7%) without SIH (odds ratio [OR] = 3.71; 95% confidence interval [CI], 1.24-11.09; P = .018 after fitting a multiple logistic regression model to adjust for age, body mass index [BMI], and surgery duration). Intraoperative BGC >140 mg/dL was also associated with an increased risk of postoperative infections (OR = 3.10; 95% CI, 1.43-6.75; P = .004). Elevated preoperative glycated hemoglobin (HbA1c) concentration was also associated with postoperative infections in the study population (OR = 2.4; 95% CI, 1.02-6.00; P = .045). Age, BMI, American Society of Anesthesiologists (ASA) physical status, type of surgery, and duration of intervention had no significant association with the postoperative infection rate. CONCLUSIONS SIH is associated with a higher risk of infections within the first postoperative week in patients undergoing elective brain neurosurgical procedures. Preoperative HbA1c is a reliable marker of the potential risk both of SIH and postoperative infections in the selected cohort. Future studies need to assess possible improvements in outcome under more precise monitoring and tighter control of perioperative hyperglycemia.
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Affiliation(s)
- Alexander Kulikov
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Yulia Krovko
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander Nikitin
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Alexander Shmigelsky
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Timur Zagidullin
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Olga Ershova
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Olga Gadzhieva
- From the Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University, Rome, Italy
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Caldara M, Belgiovine C, Secchi E, Rusconi R. Environmental, Microbiological, and Immunological Features of Bacterial Biofilms Associated with Implanted Medical Devices. Clin Microbiol Rev 2022; 35:e0022120. [PMID: 35044203 PMCID: PMC8768833 DOI: 10.1128/cmr.00221-20] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The spread of biofilms on medical implants represents one of the principal triggers of persistent and chronic infections in clinical settings, and it has been the subject of many studies in the past few years, with most of them focused on prosthetic joint infections. We review here recent works on biofilm formation and microbial colonization on a large variety of indwelling devices, ranging from heart valves and pacemakers to urological and breast implants and from biliary stents and endoscopic tubes to contact lenses and neurosurgical implants. We focus on bacterial abundance and distribution across different devices and body sites and on the role of environmental features, such as the presence of fluid flow and properties of the implant surface, as well as on the interplay between bacterial colonization and the response of the human immune system.
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Affiliation(s)
- Marina Caldara
- Interdepartmental Center on Safety, Technologies, and Agri-food Innovation (SITEIA.PARMA), University of Parma, Parma, Italy
| | - Cristina Belgiovine
- IRCCS Humanitas Research Hospital, Rozzano–Milan, Italy
- Scuola di Specializzazione in Microbiologia e Virologia, Università degli Studi di Pavia, Pavia, Italy
| | - Eleonora Secchi
- Institute of Environmental Engineering, ETH Zürich, Zürich, Switzerland
| | - Roberto Rusconi
- IRCCS Humanitas Research Hospital, Rozzano–Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele–Milan, Italy
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Systematic Review of Enhanced Recovery After Surgery in Patients Undergoing Cranial Surgery. World Neurosurg 2021; 158:279-289.e1. [PMID: 34740831 DOI: 10.1016/j.wneu.2021.10.176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures. METHODS A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society's RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes). RESULTS Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction. CONCLUSIONS ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.
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Affiliation(s)
- Tamer Albataineh
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA
| | - Sugoto Mukherjee
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA
| | - Joseph H Donahue
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA
| | - Sohil H Patel
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, VA.
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12
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Zheng G, Cao Y, Liu C, Qian L, Cai Y, Cui M, Sun H, Hong L, Yuan J, Zhang L, Zhang G. Phenotype, molecular characterisation and risk factors for postoperative meningitis caused by ESBL-producing-Enterobacteriaceae: a six years multi-Centre comparative cohort study. BMC Infect Dis 2021; 21:85. [PMID: 33468073 PMCID: PMC7816392 DOI: 10.1186/s12879-021-05784-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To determine the phenotype, molecular characterisation and risk factors of postoperative meningitis induced by Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (EPE) in China. METHODS We performed a multi-centre comparative cohort study of postoperative meningitis patients infected with Enterobacteriaceae in 4 neurosurgical centres in China from January 2014 to December 2019. Phenotype and molecular characteristics of the isolates were reviewed and tested, and independent risk factors of the EPE meningitis were evaluated by binary logistic regression. RESULTS In total, 220 Enterobacteriaceae include 78 EPE were available in this study. 85.6% (67/78) ESBL-related genes were tested, and blaSHV (14.9%) and blaSHV + blaTEM + blaCTX-M-9 (20.9%) were found to be the most frequent mono and combined ESBL-related genes harboured by Enterobacteriaceae. On binary logistic analysis, craniotomy (OR. 2.583, 95% C.I. 1.274-5.235, P = 0.008) and malignancy (OR. 2.406, 95% C.I. 1.299-4.456, P = 0.005) were the associated independent risk factors to meningitis induced by EPE. CONCLUSIONS To the best of our knowledge, this is the largest series focusing on risk factors of EPE meningitis which has been conducted in China. Craniotomy and malignancy were independent risk factors for EPE meningitis. The risk factors identified may be further utilized in clinical practice and research to avoid and reduce the mortality in future.
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Affiliation(s)
- Guanghui Zheng
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, NO. 119 Nansihuan West road, Fengtai district, Beijing, China
| | - Yanfei Cao
- Daqing Oilfield General Hospital Clinical Laboratory, No. 9 Zhongkang Street, Saltu District, Daqing, China
| | - Chunhong Liu
- Department of Clinical Diagnosis, Laboratory of Sanbo Brain Hospital and Capital Medical University, NO.50 Yikesong Road, Haidian District, Beijing, China
| | - Lingye Qian
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, NO. 119 Nansihuan West road, Fengtai district, Beijing, China
| | - Yumeng Cai
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, NO. 119 Nansihuan West road, Fengtai district, Beijing, China
| | - Miaomiao Cui
- Department of Clinical Diagnosis, Laboratory of the Second People's Hospital of Guiyang, Guiyang, China
| | - Huiting Sun
- Department of Clinical Diagnosis, Laboratory of Sanbo Brain Hospital and Capital Medical University, NO.50 Yikesong Road, Haidian District, Beijing, China
| | - Lv Hong
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, NO. 119 Nansihuan West road, Fengtai district, Beijing, China
| | - Jun Yuan
- Department of Clinical Diagnosis, Laboratory of the Second People's Hospital of Guiyang, Guiyang, China.
| | - Lina Zhang
- Daqing Oilfield General Hospital Clinical Laboratory, No. 9 Zhongkang Street, Saltu District, Daqing, China.
| | - Guojun Zhang
- Department of Clinical Diagnosis, Laboratory of Beijing Tiantan Hospital and Capital Medical University, NO. 119 Nansihuan West road, Fengtai district, Beijing, China.
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Skyrman S, Bartek J, Haghighi M, Fornebo I, Skoglund T, Jakola AS, von Vogelsang AC, Förander P. Preoperative antibiotic prophylaxis regimen in brain tumour surgery in Sweden: a quasi-experimental study. Acta Neurochir (Wien) 2020; 162:2849-2856. [PMID: 32383013 PMCID: PMC7550315 DOI: 10.1007/s00701-020-04309-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/23/2020] [Indexed: 12/26/2022]
Abstract
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.
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Catapano JS, Rubel NC, Veljanoski D, Farber SH, Whiting AC, Morgan CD, Brigeman S, Lawton MT, Zabramski JM. Standardized Ventriculostomy Protocol without an Occlusive Dressing: Results of an Observational Study in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 131:e433-e440. [DOI: 10.1016/j.wneu.2019.07.183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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Rubeli SL, D’Alonzo D, Mueller B, Bartlomé N, Fankhauser H, Bucheli E, Conen A, Fandino J, Fux CA. Implementation of an infection prevention bundle is associated with reduced surgical site infections in cranial neurosurgery. Neurosurg Focus 2019; 47:E3. [DOI: 10.3171/2019.5.focus19272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to quantify surgical site infection (SSI) rates after cranial neurosurgery in a tertiary care hospital, identify risk factors for SSI, and evaluate the impact of standardized surveillance and an infection prevention bundle (IPB).METHODSThe authors compared SSI rates during 7 months before and after the intervention. The IPB included standardized patient preparation, perioperative antibiotic/antiseptic use, barrier precautions, coaching of surgeons, and the implementation of a specialized technical operation assistant team.RESULTSThree hundred twenty-two unselected consecutive patients were evaluated before the IPB, and 296 were evaluated after implementation. Infection rates after 1 year decreased from 7.8% (25/322) to 3.7% (11/296, p = 0.03) with similar mortality rates (14.7% vs 13.8%, p = 0.8). The isolated bacteria included Staphylococcus aureus (42%), Cutibacterium acnes (22%), and coagulase-negative staphylococci (14%). Organ/space infections dominated with 67%, and mostly consisted of subdural empyema and meningitis/ventriculitis. Among the 36 SSIs, 13 (36%) occurred during hospitalization, and 29 (81%) within the first 3 months of follow-up. In multivariable analysis including established risk factors described in the literature, non-CNS neoplasia (odds ratio [OR] 3.82, 95% confidence interval [CI] 1.39–10.53), postoperative bleeding (OR 4.09, 1.44–11.62), operations performed by or under supervision of a senior faculty surgeon (OR 0.38, 0.17–0.84), and operations performed after the implementation of standardized surveillance and an IPB (OR 0.38, 0.17–0.85) significantly influenced the infection rate.CONCLUSIONSThe introduction of an IPB combined with routine surveillance and personal feedback was associated with a 53% reduced infection rate. The lower infection rates of senior faculty and the strong association between postoperative bleeding and infection underline the importance of both surgical experience as well as thorough supervision and coaching of younger surgeons.
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Affiliation(s)
| | | | - Beate Mueller
- Departments of 1Infectious Diseases and Hospital Hygiene,
| | | | | | - Evelin Bucheli
- Departments of 1Infectious Diseases and Hospital Hygiene,
| | - Anna Conen
- Departments of 1Infectious Diseases and Hospital Hygiene,
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Chen Y, Zhang L, Qin T, Wang Z, Li Y, Gu B. Evaluation of neurosurgical implant infection rates and associated pathogens: evidence from 1118 postoperative infections. Neurosurg Focus 2019; 47:E6. [DOI: 10.3171/2019.5.focus18582] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 05/22/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVEVarious implanted materials are used in neurosurgery; however, there remains a lack of pooled data on infection rates (IRs) and infective bacteria over past decades. The goal of this study was to investigate implant infections in neurosurgical procedures in a longitudinal retrospective study and to evaluate the IRs of neurosurgically implanted materials and the distribution of pathogenic microorganisms.METHODSA systematic literature search was conducted using PubMed and Web of Science databases for the time period between 1968 and 2018. Neurosurgical implant infections were studied in 5 subgroups, including operations or diseases, implanted materials, bacteria, distribution by country, and time periods, which were obtained from the literature and statistically analyzed. In this meta-analysis, statistical heterogeneity across studies was tested by using p values and I2 values between studies of associated pathogens. Egger’s test was used for assessing symmetries of funnel plots with Stata 11.0 software. Methodological quality was assessed to judge the risk of bias according to the Cochrane Handbook.RESULTSA total of 22,971 patients from 227 articles satisfied the study’s eligibility criteria. Of these, 1118 cases of infection were reported, and the overall IR was 4.87%. In this study, the neurosurgical procedures or disorders with the top 3 IRs included craniotomy (IR 6.58%), cranioplasty (IR 5.89%), and motor movement disorders (IR 5.43%). Among 13 implanted materials, the implants with the top 3 IRs included polypropylene-polyester, titanium, and polyetheretherketone (PEEK), which were 8.11%, 8.15%, and 7.31%, respectively. Furthermore, the main causative pathogen was Staphylococcus aureus and the countries with the top 3 IRs were Denmark (IR 11.90%), Korea (IR 10.98%), and Mexico (IR 9.26%). Except for the low IR from 1998 to 2007, the overall implant IR after neurosurgical procedures was on the rise.CONCLUSIONSIn this study, the main pathogen in neurosurgery was S. aureus, which can provide a certain reference for the clinic. In addition, the IRs of polypropylene-polyester, titanium, and PEEK were higher than other materials, which means that more attention should be paid to them. In short, the total IR was high in neurosurgical implants and should be taken seriously.
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Affiliation(s)
- Ying Chen
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Linyan Zhang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Tingting Qin
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhenzhen Wang
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Ying Li
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
| | - Bing Gu
- 1Department of Microbiology and Immunology, School of Medical Technology, Xuzhou Medical University; and
- 2Clinical Microbiology Laboratory, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Hussein K, Rabino G, Feder O, Eghbaryeh H, Zayyad H, Sviri G, Benenson R, Paul M. Risk factors for meningitis in neurosurgical patients with cerebrospinal fluid drains: prospective observational cohort study. Acta Neurochir (Wien) 2019; 161:517-524. [PMID: 30666453 DOI: 10.1007/s00701-019-03801-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/04/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage or intracranial pressure (ICP) monitoring devices are life-saving devices. We examined the risk factors for infections related to them and assessed the effect of an infection control (IC) intervention. METHODS A prospective observational study was conducted in the Neurosurgical Department of our hospital between 2014 and 2017. We included all consecutive patients undergoing CSF catheter insertions, including external ventricular drainage (EVD), lumbar drainage (LD), and ICP catheters. An IC intervention was implemented between March and August 2016. We examined risk factors for meningitis or ventriculitis, defined according to Healthcare-associated infections surveillance definitions, on univariate and multivariate analysis. RESULTS A total of 232 patients with 437 drains (212 EVDs, 92 LDs, and 133 ICPs) were included. On univariate and multivariate analysis, the infection incidence was 13.7 per 1000 drain days (17.3/1000 before IC intervention, 7.9/1000 during, and 9.2/1000 after the intervention). Most episodes were caused by Gram-negative bacteria, and the most common pathogen was Acinetobacter baumanii. Risk factors for infection per patient included diabetes mellitus (p = 0.017), CSF leak (p = 0.032), drain opening (p = 0.027), and the duration of the drain in days (p = 0.035). Risk factors per catheter included drain opening (p < 0.001), drain days (p = 0.001), and the IC intervention period compared to before the intervention period (p = 0.037). When restricting the analysis to EVDs, drain days (p = 0.001) was the only significant risk factor. CONCLUSIONS Strict adherence to IC, shortening drain duration, and avoiding unnecessary opening and manipulation of the drains are crucial to preventing neurosurgical drain infections.
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Affiliation(s)
- Khetam Hussein
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel.
| | - Galit Rabino
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Omri Feder
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Haneen Eghbaryeh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hiba Zayyad
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Gil Sviri
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Rima Benenson
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, P.O. Box 9602, 31096, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Renz N, Özdirik B, Finger T, Vajkoczy P, Trampuz A. Infections After Cranial Neurosurgery: Prospective Cohort of 103 Episodes Treated According to a Standardized Algorithm. World Neurosurg 2018; 116:e491-e499. [DOI: 10.1016/j.wneu.2018.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 10/14/2022]
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Valentini L, Chiaffarino F, Bonfanti N, Pannacci M, Cortellazzi P, Uberti-Foppa C, Furlanetto M, DI Meco F, Massimi L. Incidence and risk factors of neurosurgical site infections: results of a prospective multicenter cohort study on 6359 surgeries. J Neurosurg Sci 2018; 65:24-32. [PMID: 29582969 DOI: 10.23736/s0390-5616.18.04322-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neurosurgical surgical site infections (SSI) are life-threatening complications, requiring medical treatment and additional surgeries and remain a substantial cause of morbidity. In order to identify the incidence and the main risk factors for SSI, we developed the Prophylaxis with Antibiotic Protocol for Neurosurgical Site Infections Study (PASSIS), a prospective observational multicenter cohort study for examining a large number of neurosurgical procedures. METHODS The study PASSIS involved four Italian departments of neurosurgery applying the same antibiotic prophylaxis (ABP) protocol on 6359 consecutive neurosurgical procedures. In high-risk conditions (intra-operative contamination and/or postoperative cerebro-spinal fluid [CSF], and/or subcutaneous drainage and/or postoperative hyperpyrexia) and in presence of wound complication (CSF leak and/or CSF collection and/or wound diastasis), a prolongation protocol was prescribed. RESULTS The crude rate of SSI in the whole series was and 1.7% for patient and 1.5% for procedure. Patient related SSI risk factors: Younger patients (≤14 years) had a significantly higher SSI risk compared with older patients (RR: 2.17; 95% CI: 1.13-4.14). Patients underwent two surgeries were at increased SSI risk (RR: 3.80; 95% CI: 2.33-6.18), and the risk increased with the number of surgeries. Surgeries lasting longer than 3 hours (RR: 2.27; 95% CI: 1.15-4.50), undergoing two or more surgeries and the presence of prosthetic implants (RR: 2.40; 95% CI: 1.53-3.77) were procedure related SSI risk factors positively associated with SSI. In high-risk conditions and in wound complication as defined previously, ABP prolongation showed limited efficacy (RR:1.97; 95% CI: 1.21-3.22 and 9.31; 95% CI: 5.90-14.68 respectively). CONCLUSIONS The subjects submitted to complicated, repeated, long lasting craniotomies, especially if experiencing postoperative deterioration, display the higher risk of SSIs, as a final life-threatening complication. In order to reduce the SSI rate, further studies should address to design tailored prophylaxis protocols for each high risk situation as hereby defined; the wound complications deserve an increased microbiological surveillance, focusing the attention on the timing and source of infections.
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Affiliation(s)
- Laura Valentini
- Department of Neurosurgery, Neurological Institute Foundation Carlo Besta, Milan, Italy - .,-
| | - Francesca Chiaffarino
- Department of Neurosurgery, Neurological Institute Foundation Carlo Besta, Milan, Italy
| | - Nicoletta Bonfanti
- Department of Neurosurgery, Ospedale di Circolo of Varese, Varese, Italy
| | - Marilou Pannacci
- Department of Neurosurgery, Neurological Institute Foundation Carlo Besta, Milan, Italy
| | - Paolo Cortellazzi
- Department of Neuroanesthesia and Intensive Care, Neurological Institute Foundation Carlo Besta, Milan, Italy
| | - Caterina Uberti-Foppa
- Department of Infectious Diseases, Scientific Institute, San Raffaele Hospital, Milan, Italy
| | - Marika Furlanetto
- Department of Neurosurgery, Neurological Institute Foundation Carlo Besta, Milan, Italy
| | - Francesco DI Meco
- Department of Neurosurgery, Neurological Institute Foundation Carlo Besta, Milan, Italy
| | - Luca Massimi
- Department of Pediatric Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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