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Huang TF, Su YK, Su IC, Yeh YK, Liu HW, Kan IH, Lu YC, Chang YP, Lin CM, Tu YK, Tseng CH. Risk, Predictive, and Preventive Factors for Noninfectious Ventriculitis and External Ventricular Drain Infection. Neurocrit Care 2024:10.1007/s12028-023-01925-9. [PMID: 38253924 DOI: 10.1007/s12028-023-01925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND External ventricular drain (EVD) is used for monitoring intracranial pressure or diverting cerebrospinal fluid. However, confirmation of an infection is not immediate and requires obtaining culture results, often leading to the excessive use of antibiotics. This study aimed to compare noninfectious ventriculitis and EVD infection in terms of the risk factors, predictors, prognosis, and effectiveness of care bundle interventions. METHODS This retrospective study was conducted at a medical center with 1,006 beds in northern Taiwan between January 2018 and July 2022. Standard EVD insertion protocols and care bundles have been implemented since 2018, along with the initiation of chlorhexidine. RESULTS In total, 742 EVD cases were identified. Noninfectious ventriculitis typically presents with fever approximately 8 days following EVD placement, whereas EVD infection typically manifests as fever after 20 days. Aneurysmal subarachnoid hemorrhage was strongly associated with the development of noninfectious ventriculitis (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.5-4.4). Alcoholism (adjusted OR 3.5, 95% CI 1.1-12.3) and arteriovenous malformation (adjusted OR 13.1, 95% CI 2.9-58.2) significantly increased the risk of EVD infection. The EVD infection rate significantly decreased from 3.6% (14 of 446) to 1.0% (3 of 219) (p = 0.03) after the implementation of chlorhexidine gluconate bathing. CONCLUSIONS Aneurysmal subarachnoid hemorrhage or fever with neuroinflammation within 2 weeks of EVD placement is indicative of a higher likelihood of noninfectious ventriculitis. Conversely, patients with arteriovenous malformation, alcoholism, or fever with neuroinflammation occurring after more than 3 weeks of EVD placement are more likely to necessitate antibiotic treatment for EVD infection. Chlorhexidine gluconate bathing decreases EVD infection.
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Affiliation(s)
- Tzu-Fen Huang
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Kai Su
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Chang Su
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yun-Kai Yeh
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, Taiwan
| | - Heng-Wei Liu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan
| | - I-Hung Kan
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chun Lu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Yu-Pei Chang
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Min Lin
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yong-Kwang Tu
- Division of Neurosurgery, Department of Surgical Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Hua Tseng
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.
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2
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Marino AC, Robinson ED, Durden JA, Cox HL, Mathers AJ, Shaffrey ME. The effects of avoiding extended antimicrobial drain prophylaxis on Clostridioides difficile and postprocedural infection rates: a 5-year retrospective. J Neurosurg 2022; 137:1153-1159. [PMID: 35171828 DOI: 10.3171/2021.11.jns211459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postprocedural infection is a consequential complication of neurosurgical intervention. Periprocedural antimicrobial prophylaxis is routinely administered to prevent infection, and in some cases, continued for extended periods while surgical drains remain in place. However, there is little evidence that extended antimicrobial administration is necessary to reduce postprocedural infection, and extended antimicrobials can be associated with harm, such as Clostridioides difficile infection. The authors sought to evaluate whether shortening the duration of postprocedural antimicrobial prophylaxis would decrease the incidence of C. difficile infection without increasing the incidence of postprocedural infection. METHODS In this retrospective study, two general neurosurgical cohorts were examined. In one cohort, postoperative antimicrobial prophylaxis was limited to 24 hours; in the other, some patients received extended postoperative antimicrobial prophylaxis while surgical drains or external ventricular drains (EVDs) remained in place. Rates of infection with C. difficile as well as postprocedural infection after surgery and EVD placement were compared. RESULTS Seven thousand two hundred four patients undergoing 8586 surgical procedures and 413 EVD placements were reviewed. The incidence of C. difficile infection decreased significantly from 0.5% per procedural encounter to 0.07% with the discontinuation of extended postprocedural antibiotics within 90 days of a procedure. Rates of postprocedural infection and EVD infection did not significantly change. Results were similar in subgroups of patients with closed suction drains as well as cranial and spine subgroups. CONCLUSIONS Discontinuation of extended antimicrobial prophylaxis was associated with a significant decrease in the incidence of C. difficile infection without a concomitant change in postprocedural infections or EVD-associated infection. This study provides evidence in support of specialtfy-wide discontinuation of extended postoperative antimicrobial prophylaxis, even in the presence of closed suction drains.
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Affiliation(s)
| | - Evan D Robinson
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
| | | | - Heather L Cox
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
- 4Department of Pharmacy Services, University of Virginia Health, Charlottesville, Virginia
| | - Amy J Mathers
- 2Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia
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3
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Walton MN, Hamilton LA, Kennedy SJ, Veve MP, Rowe AS. Antibiotic Prophylaxis and Incidence of Infection with External Ventricular Drains and Intra-Cranial Pressure Monitors. Surg Infect (Larchmt) 2022; 23:262-269. [PMID: 35133886 DOI: 10.1089/sur.2021.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Guidelines do not recommend extended antibiotic prophylaxis for external ventricular drains (EVD) or intra-cranial pressure (ICP) monitors. The study objective was to determine if infection rates are different for patients receiving antibiotic prophylaxis for EVD or ICP monitors. Patients and Methods: This single-center retrospective cohort reviewed intensive care unit patients who had an EVD or ICP monitor placed. Patients receiving antibiotic prophylaxis were compared with those who did not receive prophylaxis. The primary end point was incidence of central nervous system (CNS) infection. Results: Overall, 228 patients were included, 120 of whom received prophylaxis and 108 who did not receive prophylaxis. The primary end point of CNS infection was not different between groups (18 [17%] vs. 23 [19%]; p = 0.6236). Conclusions: Antibiotic prophylaxis was not associated with a decreased incidence of CNS infection in patients with EVD or ICP monitors. Evaluation of antibiotic use in this patient population is warranted to prevent resistance and adverse drug effects.
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Affiliation(s)
- Mary N Walton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Leslie A Hamilton
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA.,University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
| | - Sonia J Kennedy
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Michael P Veve
- Wayne State University College of Pharmacy and Health Sciences, Detroit, Michigan, USA
| | - A Shaun Rowe
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, Tennessee, USA.,University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
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4
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Kerry G, Holtmannspoetter M, Kubitz JC, Steiner HH. Factors which influence the complications of external ventricular cerebrospinal fluid drainage. Acta Neurochir (Wien) 2022; 164:483-493. [PMID: 34626273 DOI: 10.1007/s00701-021-05007-7] [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: 08/01/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND External ventricular drainage (EVD) is one of the most common neurosurgical procedures in emergencies. This study aims to find out which factors influence the occurrence of EVD-related complications in a comparative investigation of metal needles and polyurethane catheters. This is the first clinical study comparing these two systems. METHODS Adult patients undergoing pre-coronal EVD placement via freehand burr hole trepanation were included in this prospective study. The exclusion criteria were the open EVD insertion and/or a pre-existing infectious disease of the central nervous system. RESULTS Two hundred consecutive patients were enrolled. Of these, 100 patients were treated by using metal EVD (group 1) and 100 patients with polyurethane catheters (group 2). The overall complication rate was 26% (misplacement 13.5%, hemorrhage 12.5%, infection 2.5%, and dislocation 1%) without statistically significant differences between both groups. Generalized brain edema and midline shift had a significant influence on misplacements (generalized brain edema: p = 0.0002, Cramer-V: 0.307, OR = 7.364, 95% CI: 2.691-20.148; all patients: p = 0.001, Cramer-V: 0.48, OR = 43.5, 95% CI: 4.327-437.295; group 1: p = 0.047, Cramer-V: 0.216, OR = 3.75, 95% CI: 1.064-13.221; group 2: midline shift: p = 0.038, Cramer-V: 0.195, OR = 3.626, 95% CI: 1.389-9.464) all patients: p = 0.053, Cramer-V: 0.231, OR = 5.533, 95% CI 1.131-27.081; group 1: p = 0.138, Cramer-V: 0.168, OR = 2.769, 95% CI: 0.813-9.429 group 2. Hemorrhages were associated with the use of oral anticoagulants or antiplatelet therapy (p = 0.002; Cramer-V: 0.220, OR = 3.798, 95% CI: 1.572-9.175) with a statistically similar influence in both groups. CONCLUSION Generalized brain edema has a significant influence on misplacements in both groups. Midline shift lost its significance when considering only the patients in group 2. Patients under oral anticoagulation and antiplatelet therapy have increased odds of EVD-associated hemorrhage. Metal needles and polyurethane catheters are equivalent in terms of patient safety when there are no midline shift and generalized brain edema.
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Affiliation(s)
- Ghassan Kerry
- Department of Neurosurgery, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany.
- Medical Faculty, University of Heidelberg, Heidelberg, Germany.
| | - Markus Holtmannspoetter
- Department of Neuroradiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Jens Christian Kubitz
- Department of Anesthesiology, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Klinikum Nuremberg, Paracelsus Medical University, Nuremberg, Germany
- Medical Faculty, University of Heidelberg, Heidelberg, Germany
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5
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Zakaria J, Jusue-Torres I, Frazzetta J, Rezaii E, Costa R, Ballard M, Sethi N, Parada J, Prabhu VC. Effectiveness of a Standardized External Ventricular Drain Placement Protocol for Infection Control. World Neurosurg 2021; 151:e771-e777. [PMID: 33957282 DOI: 10.1016/j.wneu.2021.04.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Placement of an external ventricular drain (EVD) is a common procedure routinely completed at bedside by neurosurgical residents. A standardized protocol for placement and maintenance of an EVD is potentially useful. METHODS This single-institution retrospective review analyzed all patients who underwent placement of an EVD over a 5-year span using a standardized protocol. RESULTS A total of 428 EVDs in 381 patients were placed as per this protocol. Overall compliance with the practice protocol was 98.7%. Overall, our infection rate was 1.86% (8 external ventricular drain-related infection [ERIs] over 428 EVDs). There was no difference in age for the ERI cases (median 55, range (50.5-60.5), compared with the non-ERI cases (median of 53, range [38-65]) (P = 0.512). Indications for placement of EVD were hemorrhage (51.9%, n = 198), tumor (16.2%, n = 62), trauma (12.8%, n = 49), hydrocephalus (11.5%, n = 44), cerebellar stroke (2.8%, n = 11), infection (3.1%, n = 12), unknown (1.3%, n = 5). Most EVDs (77.6%, n = 296) were placed bedside by second-year residents (median PGY level 2, interquartile range 1-2.75). Computed tomography confirmed placement in the ipsilateral frontal horn in 72% (n = 277) of EVDs. EVD-related complications were noted in 8.3% of EVDs (n = 32, with 8 infections and 24 tract hemorrhages). The median EVD duration was 10 days; duration of EVD had no statistically significant impact on the risk of an ERI (P = 1). Only replacement of an EVD was associated with an increased risk of infection. CONCLUSIONS Adherence to a standard EVD placement protocol is useful in maintaining a low risk of ERI regardless of the duration of catheter utilization. Replacement of the catheter through the same access hole as the original catheter is associated with an increased risk of ERI.
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Affiliation(s)
- Jehad Zakaria
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Ignacio Jusue-Torres
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Joseph Frazzetta
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Elhaum Rezaii
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Renzo Costa
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Matthew Ballard
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Neil Sethi
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Jorge Parada
- Department of Medicine, Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Vikram C Prabhu
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA.
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6
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Effect of a bundle approach on external ventricular drain-related infection. Acta Neurochir (Wien) 2021; 163:1135-1142. [PMID: 33427989 DOI: 10.1007/s00701-020-04698-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Emergency placement of an external ventricular drain (EVD) is one of the most frequently performed neurosurgical procedures. EVD-related infection continues to be a major challenge causing significant morbidity and costs. Bundle approaches have been shown to reduce infection rates; however, they are still not widely used, and observation periods often were rather short. METHODS The present study evaluated the effect of a multi-item bundle approach for EVD placement and care on the occurrence of EVD-related infection. A before/after approach was used to compare groups of consecutive patients over 5-year epochs to control for bias and secondary confounding variables. RESULTS The number of patients in the group before implementation of the bundle approach was 141 and 208 thereafter. There were no statistical differences in demographic and other variables. While 41/141 patients (29.1%) had an EVD-related infection before, this was the case in only 10/208 patients (4.8%) thereafter (p < 0.0001). The EVD-related infection rate was reduced from 13.7/1000 catheter days to 3.2/1000, and the 50% probability of an EVD-related infection in correlation to the mean duration of EVD placement was significantly lower (p < 0.0001). Routine EVD replacement was not helpful to reduce EVD-related infection. EVD-related infection rates remained low also over the next 8 years after the study was finished. CONCLUSIONS The introduction of a multi-item bundle approach for EVD insertion and care resulted in a marked reduction of EVD-related infection. Long observation periods over 5 years and beyond confirm that short-term changes are sustained with continued use of such protocols.
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7
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Sheppard JP, Ong V, Lagman C, Udawatta M, Duong C, Nguyen T, Prashant GN, Plurad DS, Kim DY, Yang I. Systemic Antimicrobial Prophylaxis and Antimicrobial-Coated External Ventricular Drain Catheters for Preventing Ventriculostomy-Related Infections: A Meta-Analysis of 5242 Cases. Neurosurgery 2020; 86:19-29. [PMID: 30476297 DOI: 10.1093/neuros/nyy522] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 10/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND External ventricular drain (EVD) placement is essential for the management of many neurocritical care patients. However, ventriculostomy-related infection (VRI) is a serious complication, and there remains no well-established protocol guiding use of perioperative or extended antibiotic prophylaxis to minimize risk of VRI. OBJECTIVE To analyze published evidence on the efficacy of extended prophylactic antimicrobial therapy and antibiotic-coated external ventricular drains (ac-EVDs) in reducing VRI incidence. METHODS We searched PubMed for studies related to VRIs and antimicrobial prophylaxis. Eligible articles reported VRI incidence in control and treatment cohorts evaluating prophylaxis with either extended systemic antibiotics (> 24 hr) or ac-EVD. Risk ratios and VRI incidence were aggregated by prophylactic strategy, and pooled estimates were determined via random or mixed effects models. Study heterogeneity was quantified using I2 and Cochran's Q statistics. Rigorous assessment of study bias was performed, and PRISMA guidelines were followed throughout. RESULTS Across 604 articles, 19 studies (3%) met eligibility criteria, reporting 5242 ventriculostomy outcomes. Extended IV and ac-EVD prophylaxis were associated with risk ratios of 0.36 [0.14, 0.93] and 0.39 [0.21, 0.73], respectively. Mixed effects analysis yielded expected VRI incidence of 13% to 38% with no prophylaxis, 7% to 18% with perioperative IV prophylaxis, 3% to 9% with either extended IV or ac-EVD prophylaxis as monotherapies, and as low as 0.8% to 2% with extended IV and ac-EVD dual prophylaxis. CONCLUSION Management with both extended systemic antibiotics and ac-EVDs could lower VRI risk in ventriculostomy patients, but the impact on associated morbidity and mortality, healthcare costs, and length of stay remain unclear.
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Affiliation(s)
- John P Sheppard
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Vera Ong
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Carlito Lagman
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Methma Udawatta
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Courtney Duong
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Thien Nguyen
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - Giyarpuram N Prashant
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California
| | - David S Plurad
- Department of Trauma Surgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Dennis Y Kim
- Department of Trauma Surgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
| | - Isaac Yang
- Department of Neurosurgery, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Head and Neck Surgery, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Radiation Oncology, Ronald Regan UCLA Medical Center, Los Angeles, California.,Jonsson Comprehensive Cancer Center, Ronald Regan UCLA Medical Center, Los Angeles, California.,Department of Neurosurgery, Harbor-UCLA Medical Center, Los Angeles, California.,Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, California
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8
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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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9
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Carroll E, Lewis A. Prevention of surgical site infections after brain surgery: the prehistoric period to the present. Neurosurg Focus 2019; 47:E2. [PMID: 31370023 DOI: 10.3171/2019.5.focus19250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 05/01/2019] [Indexed: 11/06/2022]
Abstract
In this historical vignette, the authors discuss the prevention of surgical site infections (SSIs) after brain surgery from the prehistoric period to the present. Although the mechanism for infection was not fully understood until the 19th century, records demonstrate that as early as 10,000 bc, practitioners used gold, a biocidal material, for cranioplasties and attempted to approximate wounds by tying a patient's hair across the incision. Written records from the Egyptian and Babylonian period depict the process of soaking head dressings in alcohol, an antibacterial agent. In the Greek and Early Byzantine period, Hippocrates argued against the formation of pus in wounds and continued to champion the use of wine in wound management. In the 16th century, intracranial silver drains were first utilized in an effort to prevent postoperative infections. The turning point of SSI prevention was in 1867, when Joseph Lister illustrated the connection between Louis Pasteur's discovery of the fermentation process and the suppuration of wounds. Today, there are ongoing investigations and debates about the optimal techniques to prevent SSI after brain surgery. Although tremendous progress in the field of SSI prevention since the prehistoric period has been made, SSI continues to affect morbidity and mortality after brain surgery.
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Affiliation(s)
| | - Ariane Lewis
- Departments of1Neurology and.,2Neurosurgery, NYU Langone Medical Center, New York, New York
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10
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Alunpipatthanachai B, Thirapattaraphan P, Fried H, Vavilala MS, Lele AV. External Ventricular Drain Management Practices in Thailand: Results of the EPRACT Study. World Neurosurg 2019; 126:e743-e752. [PMID: 30851470 DOI: 10.1016/j.wneu.2019.02.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We explored the external ventricular drain (EVD) practices in Thailand. METHODS We performed a survey-based study to describe EVD insertion, maintenance, quality improvement (QI) practices, and incidence of EVD infection. RESULTS The study included 58 of 101 hospitals contacted (57.4% response rate), with ≥600 beds (44.8%) and dedicated neurocritical care units (53%). The reasons for EVD placement included aneurysmal subarachnoid hemorrhage, traumatic brain injury, and ventriculoperitoneal shunt malfunction or infection; 75.9% of the hospitals cared for ≤100 EVDs annually. In Thailand, nonantimicrobial EVD catheters (98.3%) were used most often. Most hospitals (56.9%) did not routinely sample the cerebrospinal fluid. Prophylactic daily antibiotic use was prevalent (62.1%). Most hospitals (77.6%) did not measure the intracranial pressure during intrahospital transport. EVD infection was a commonly (69%) tracked QI measure; however, up to one third of the hospitals did not track any EVD QI measure. Most hospitals (94.8%) had no written EVD insertion and maintenance protocols. Most hospitals (79.3%) reported an EVD infection rate of ≤5% in the previous year. The low EVD infection rate, high cost, and/or the lack of equipment could account for the low usage of antimicrobial catheters and intracranial pressure monitoring. CONCLUSIONS The results of the present study have identified QI opportunities in EVD management in Thailand. The development of an EVD-related QI process, reliable tracking of EVD infection rates, adaptation of U.S. guidelines to create standardized EVD protocols, and examination of the association between EVD practices and clinical outcomes in low-to middle-income countries are urgently needed.
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Affiliation(s)
- Bhunyawee Alunpipatthanachai
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Porntip Thirapattaraphan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Khon Kaen University, Muang, Khon Kaen, Thailand
| | - Herbert Fried
- Department of Neurological Surgery, University of Colorado, Aurora, Colorado, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
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11
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Lewis A, Rothstein A, Pacione D. Results of a quality improvement initiative reassessing an institutional lumbar drain infection prevention protocol. J Neurosurg Spine 2018; 29:54-58. [PMID: 29701568 DOI: 10.3171/2017.11.spine171023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effects of a quality improvement initiative in which daily antibiotics and daily sampling of cerebrospinal fluid (CSF) were discontinued for patients with lumbar drains. METHODS The frequency of surgical site infections (SSIs), antibiotic-related complications (development of Clostridium difficile infection [CDI] and growth of resistant bacteria), and cost for patients with lumbar drains were compared during 3 periods: 1) prolonged prophylactic systemic antibiotics (PPSA) until the time of drain removal and daily CSF sampling (September 2013-2014), 2) PPSA and CSF sampling once after placement then as needed (January 2015-2016), and 3) antibiotics only during placement of the lumbar drain and CSF sampling once after placement then as needed (April 2016-2017). RESULTS Thirty-nine patients were identified in period 1, 53 patients in period 2, and 39 patients in period 3. There was no change in the frequency of SSI after discontinuation of routine CSF testing or PPSA (0% in period 1, 2% in period 2, and 0% in period 3). In periods 1 and 2, 3 patients developed infections due to resistant organisms and 2 patients had CDI. In period 3, 1 patient had an infection due to a resistant organism. The median cost of CSF tests per patient was $100.68 (interquartile range [IQR] $100.68-$134.24) for patients in period 1 and $33.56 (IQR $33.56-$33.56) in periods 2 and 3 (p < 0.001). The median cost of antibiotics per patient was $26.32 (IQR $26.32-$30.65) in periods 1 and 2 and $3.29 ($3.29-$3.29) in period 3 (p < 0.001). The cost associated with growth of resistant bacteria and CDI was $91,291 in periods 1 and 2 and $25,573 in period 3. CONCLUSIONS After discontinuing daily antibiotics and daily CSF sampling for patients with lumbar drains, the frequency of SSI was unchanged and the frequency of antibiotic-related complications decreased.
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Affiliation(s)
- Ariane Lewis
- Departments of1Neurology and.,2Neurosurgery, NYU Langone Medical Center, New York, New York
| | | | - Donato Pacione
- 2Neurosurgery, NYU Langone Medical Center, New York, New York
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