Topical antibiotics in neurosurgery: a re-evaluation of the Malis technique

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

Background

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

Methods

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

Results

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

Conclusion

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

Risk factors for meningitis after craniotomy in patients with subarachnoid hemorrhage due to anterior circulation aneurysms rupture

OBJECTIVES

Postoperative meningitis is a serious complication occurring after neurosurgical interventions. However, few investigations have focused specifically on the risk factors that predispose patients to meningitis after major craniotomy. This study identified the risk factors for postoperative meningitis after neurovascular surgery, and investigated the relationship between postoperative meningitis and clinical outcome.

PATIENTS AND METHODS

A total of 148 consecutive patients with subarachnoid hemorrhage (SAH) who underwent clipping surgery through a pterional approach within 72 h between January 2007 and September 2011 were retrospectively analyzed. The treatment strategy of our hospital for patients with SAH was based on the findings of digital subtraction angiography in the acute phase. Coil embolization was firstly considered, and clipping through craniotomy if indicated was performed as soon as possible. Prophylactic antibiotics were administered before beginning craniotomy and for at least 3 days after. Hydrocortisone was used to prevent hyponatremia if allowed by the medical condition of the patient. Intrathecal administration of nicardipine hydrochloride was given if required for vasospasm treatment. Meningitis was clinically diagnosed from the blood samplings and cerebrospinal fluid (CSF) examinations. Data were collected from the electronic and paper charts. The status of modified Rankin scale (mRS) 0-2 at discharge was defined as favorable outcome.

RESULTS

A total of 14 patients (9.5%) had meningitis during this study period. Symptomatic vasospasm was detected in 33 patients (22.3%), and 12 patients (8.1%) had permanent neurological deficits caused by vasospasm. Overall, 109 patients (73.6%) had favorable outcome. The longer duration of drainage placement, presence of CSF leakage, and intrathecal administration of vasodilatory agent showed significantly higher incidence of postoperative meningitis in univariate analysis (p=0.0093, 0.0017, and 0.0090, respectively). The proportion of favorable outcome patients at discharge (mRS 0-2) was significantly lower in patients with postoperative meningitis (35.7%) than in patients without it (77.6%) (p=0.0004). The duration of in-hospital stay was significantly longer in patients with postoperative meningitis (median 58.5, range 28-115 days) than in patients without it (median 38.5, range 19-149 days) (p<0.001). Multivariate logistic regression analysis showed that only presence of CSF leakage was associated with postoperative meningitis (p=0.0299).

CONCLUSION

Meningitis after surgery is still a serious complication that requires preventative intervention. The clinical outcome of patients with postoperative meningitis after neurovascular surgery is not still satisfactory.

Topical antibiotics and neurosurgery: Have we forgotten to study it?

BACKGROUND

For neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques. However, the efficacy of topical antibiotic prophylaxis in neurological operations remains to be established by neurosurgeons.

METHODS

The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature. The authors performed the search by using the following Mesh terms: "neurosurgery" or "neurosurgical procedures" and "administration, topical" and "antibiotic prophylaxis"; "neurosurgery" or "neurosurgical procedures" and "administration, topical" and "antibacterial agents."

RESULTS

In the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery. All the papers reported were Class III evidence.

CONCLUSION

To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery.

Surgical site infection: incidence and impact on hospital utilization and treatment costs

BACKGROUND

Surgical site infections (SSIs) are serious operative complications that occur in approximately 2% of surgical procedures and account for some 20% of health care-associated infections.

METHODS

SSI was identified based on the presence of ICD-9-CM diagnosis code 998.59 in hospital discharge records for 7 categories of surgical procedures: neurological; cardiovascular; colorectal; skin, subcutaneous tissue, and breast; gastrointestinal; orthopedic; and obstetric and gynecologic. Source of data was the 2005 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS). Primary study outcomes were rate of SSI by surgical category and impact of SSI on length of stay and cost. Results were projected to the national level.

RESULTS

Among 723,490 surgical hospitalizations in the sample, 6891 cases of SSI were identified (1%). On average, SSI extended length of stay by 9.7 days while increasing cost by $20,842 per admission. From the national perspective, these cases of SSI were associated with an additional 406,730 hospital-days and hospital costs exceeding $900 million. An additional 91,613 readmissions for treatment of SSI accounted for a further 521,933 days of care at a cost of nearly $700 million.

CONCLUSION

SSI is associated with a significant economic burden in terms of extended length of stay and increased costs of treatment. Our analysis documented nearly 1 million additional inpatient-days and $1.6 billion in excess costs.

Postoperative intracranial neurosurgery infection rates in North America versus Europe: a systematic analysis

BACKGROUND

Postoperative wound infection (PWI) after intracranial neurosurgery remains a significant worldwide problem, resulting in substantial morbidity/mortality if not combatted quickly and energetically. Although the danger of PWI is universally recognized, the reported incidence of PWI after intracranial neurosurgery remains variable, ranging from 1% to 8% in published series. The impact of geography on this reported variability has not been previously investigated. To address this issue, published comprehensive intracranial neurosurgery series were reviewed, segregating findings geographically between North American and European series.

METHODS

A comprehensive literature search was conducted using the Entrez gateway of the PubMed database. Studies conducted in North America and Europe reporting the incidence of PWI after intracranial neurosurgery were subjected to a thorough review. Data from studies meeting inclusion criteria (minimum of 500 cases with no systematic exclusion of procedures) were categorized by origin (North American/European) and design (retrospective/prospective). Recorded incidences were then compared using chi(2) analysis, and estimates of the relative risk of PWI were calculated.

RESULTS

Seven studies (4 North American, 3 European) met all of the inclusion criteria, with a 2.6-fold greater PWI incidence reported in the European studies (P < .001). The relative risk of PWI for Europeans versus North Americans per operative case was 2.60.

CONCLUSION

PWI after intracranial neurosurgery was nearly 3 times more likely in European versus North American studies. These findings should be considered by clinicians when estimating the risks of intracranial neurosurgery, and highlight the need for future prospective studies to provide evidence-based explanations for these differences.

Efficacy of Prophylactic Antibiotics Against Meningitis after Craniotomy: A Meta-Analysis

OBJECTIVE

Although prophylactic antibiotics have been shown by randomized clinical trials (RCTs) to help prevent deep infection after craniotomies, recent reports have suggested that antibiotics are not effective in preventing postcraniotomy meningitis.

METHODS

Data on meningitis as an end point from RCTs on prophylactic antibiotics for craniotomies were pooled in a random-effects meta-analysis.

RESULTS

Six prospective randomized trials or trial subgroups enrolling 1729 patients or operations were identified. Antibiotics reduced postoperative infection rates in five of the six RCTs; no trial individually showed a statistically significant benefit from antibiotics. The pooled odds ratio for meningitis with antibiotic treatment in the six RCTs was 0.43 (95% confidence interval, 0.20–0.92; P = 0.03). Subgroup analyses showed no detectable difference in antibiotic efficacy if antibiotics, with or without gram- negative coverage, were used or if the trial was single or double blinded. A sensitivity analysis showed modest dependence of the results of the analysis on the specific definition of postoperative meningitis used in interpreting trial results.

CONCLUSION

Prophylactic antibiotics administered before craniotomy reduce rates of postoperative meningitis by approximately one-half, a statistically and clinically significant benefit.

Prevention of Postoperative Infections in Horses

The best defense against postoperative infection is to use multiple strategies to minimize wound contamination, maintain wound tissue health, and provide rational antimicrobial strategies that do not promote the development of resistant bacteria and superinfections.

Irrigation with antibiotic-containing solutions for the prevention and treatment of infections

Administration routes for antimicrobial agents used in clinical practice include the topical, inhaled, enteral and parenteral routes. An antibiotic administration route used frequently worldwide, although not well-studied, involves the irrigation of wounds with antibiotic-containing solutions for the prevention and treatment of infections. This review considers the data available from various experimental and clinical studies in order to provide an update on the use of antibiotic-containing solutions in modern clinical practice. Although irrigation with antibiotic-containing solutions has been suggested to be beneficial in the prevention or treatment of infections in several settings and patient populations, no firm, evidence-based recommendations can be made regarding its use until additional data from well-designed, randomised clinical trials become available. Current exceptions include empyema following lobectomy, or pneumonectomy and pyocystis (vesical empyema), since irrigation with solutions containing antimicrobial agents seems to be a crucial component of the management of these conditions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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