Surgical site infections after elective craniotomy for brain tumor: a study on potential risk factors and related treatments

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

BACKGROUND

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

METHOD

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

RESULT

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

CONCLUSIONS

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

An update on a persisting challenge: A systematic review and meta-analysis of the risk factors for surgical site infection post craniotomy

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.

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

Scalp necrosis following preoperative endovascular embolisation of the superficial temporal artery for meningioma

A woman in her late 50s with a left frontal lobe convexity meningioma underwent an elective endovascular embolisation of the left middle meningeal artery and distal branches of the left superficial temporal artery prior to surgical resection of the tumour. On postoperative day 46, she developed scalp necrosis, leading to poor wound healing requiring wound debridement and a complex plastic surgery reconstruction with a rotational flap. Endovascular embolisation of vascular tumours prior to surgical resection does not come without risks. The lack of consistency in the literature regarding indication, technique and outcomes makes it difficult to define the exact role of preoperative meningioma embolisation.

A meta-analysis of the risk factors for neurosurgical surgical site infection following craniotomy

The purpose of the meta-analysis was to evaluate and compare the risk factors for neurosurgical surgical site infection (SSI) after craniotomy. Using dichotomous or contentious random or fixed effect models, the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were computed based on the examination of the meta-analysis results. Eighteen analyses, covering 11 068 craniotomies between 2001 and 2023, were included in the current meta-analysis. Subjects with SSIs had a significantly younger age (MD, -2.49; 95% CI, -2.95 to -2.04, p < 0.001), longer operation duration (MD, 10.21; 95% CI, 6.49-13.94, p < 0.001) and longer length of postoperative hospital stay (MD, 1.52; 95% CI, 0.45-2.60, p = 0.006) compared to subjects with no SSI with craniotomy. However, no significant difference was found between craniotomy subjects with SSIs and with no SSI in gender (OR, 0.90; 95% CI, 0.76-1.07, p = 0.23), and combination with other infection (OR, 3.93; 95% CI, 0.28-56.01, p = 0.31). The data that were looked at showed that younger age, longer operation duration and longer length of postoperative hospital stay can be considered as risk factors of SSI in subjects with craniotomy; however, gender and combination with other infections are not. Nonetheless, consideration should be given to their values because several studies only involved a small number of patients, and there are not many studies available for some comparisons.