Efficacy of antibiotic prophylaxis in clean neurosurgical operations

Intra-operative wound irrigation with ceftriaxone does not reduce surgical site infection in clean neurosurgical procedures

BACKGROUND

The spectrum of post-operative infections in neurosurgical practice includes scalp infection, bone flap osteomyelitis, meningitis and intracranial abscesses and is associated with significant morbidity and mortality. There is a wide variation across neurosurgical centres in the use of perioperative antibiotic prophylaxis. The aim of this study was to determine whether intraoperative wound irrigation with ceftriaxone provides additional prevention of surgical site infection (SSI) in patients already receiving the drug parenterally.

METHODS

This was a prospective randomized clinical study of patients 18 years and above scheduled for clean neurosurgical procedures and assigned to either study or control group using table of random numbers. Both groups had parenteral ceftriaxone at the induction of anaesthesia and for 24-h post-operation. In the study group, there was intra-operative wound irrigation with a ceftriaxone-in-normal saline solution while the wound in the control group was irrigated with only normal saline. Clinical and or laboratory evidence of SSI was used as the outcome measure.

RESULTS

One hundred and thirty-two patients aged 18 years and above were recruited for this study. There were 66 patients in each group. The overall frequency of SSI was 2.27% (3 out of 132). The frequency in the ceftriaxone group was 3% (2 out of 66) while that in the control group was 1.5% (1 out of 66). These values were not significantly different (p = 1.00). There were four cases of wound edge necrosis, three of which developed SSIs.

CONCLUSION

In this study, intraoperative antibiotic irrigation did not confer additional benefit in the prevention of SSI in clean neurosurgical procedures in which prophylactic intravenous antibiotics were administered to the patient. Wound edge necrosis was the most significant but preventable risk factor for the development of SSI in the setting of this work.

Restoration of the Fronto-Orbital Buttress with Primary Bone Fragments

Objective

Forehead deformities are often caused by lack of treatment or incorrect restoration of the frontal buttress, so the underlying frontal buttress should be restored to its previous position to ensure that the previous forehead contour is restored in cases of complex depressed skull fractures. However, since brain injuries from skull fractures could have fatal consequences, the clinical concern in primary surgery has been to save the patient's life, and cosmetic concerns have always been secondary. We retrospectively reviewed fronto-orbital fracture patients who underwent primary restoration with primary bone fragments or an alloplastic implant and compared the surgical outcomes of autologous bone (group 1) and artificial materials (group 2).

Methods

A retrospective review was conducted of 47 patients with fronto-orbital fractures between March 2012 and January 2018. The patients underwent primary reconstruction with primary bone fragments or an alloplastic implant. The surgical results were evaluated by the incidence of infection and cosmetic satisfaction of patients.

Results

Infections occurred in one patient (5%) in group 1 and in two patients (15.3%) in group 2, which was not a statistically significant difference. In contrast, at 6 months after surgery, patient satisfaction showed a statistically significant between-group difference (group 1: 4.32 points, group 2: 3.54 points, p=0.001).

Conclusion

Primary reconstruction using fractured bone fragments is an effective and preferable method that could result in better surgical outcomes than restoration using an alloplastic implant.

Surgical management and outcomes of non-missile open head injury: Report of 44 cases from a single trauma centre

OBJECTIVE

To retrospectively analyse the surgical management and outcomes of non-missile open head injuries (NMOHI).

METHODS

Forty-four patients who suffered from NMOHI were included. The Glasgow outcome score (GOS), computed tomography (CT), aetiology and outcomes and complications at discharge and during a 6-month follow-up were analysed. All patients underwent debridement. Intracranial haematoma evacuation, decompressive craniectomy (DC) or replacement were performed.

RESULTS

Motor vehicle accident and struck by/against were the most common causes (43.2% each). At admission, 33 patients had Glasgow coma scores (GCS) > 8 and 27 of them had a GCS score of > 13. Mean follow-up was 8.7 ± 4.3 months. All patients underwent debridement, 20 underwent bone fracture replacement and 27 underwent haematoma evacuation; 11 patients underwent haematoma evacuation and DC and one had bilateral DC. Twenty-seven patients showed good recovery; 11 patients had moderate disability; three patients had severe disability; and three patients died. After 6 months, 32 patients had good recovery and the morbidity of severe disability had decreased to 13.6%. Thirteen patients developed intracranial infection. Post-traumatic epilepsy and hydrocephalus was detected in three patients. Cerebrospinal fluid fistula was found in five patients. Only one patient developed a brain abscess after 6 months.

CONCLUSIONS

NMOHI yielded satisfactory recovery and achieved good outcomes.

Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Case-control studies in neurosurgery

OBJECT

Observational studies, such as cohort and case-control studies, are valuable instruments in evidence-based medicine. Case-control studies, in particular, are becoming increasingly popular in the neurosurgical literature due to their low cost and relative ease of execution; however, no one has yet systematically assessed these types of studies for quality in methodology and reporting.

METHODS

The authors performed a literature search using PubMed/MEDLINE to identify all studies that explicitly identified themselves as "case-control" and were published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Each paper was evaluated for 22 descriptive variables and then categorized as having either met or missed the basic definition of a case-control study. All studies that evaluated risk factors for a well-defined outcome were considered true case-control studies. The authors sought to identify key features or phrases that were or were not predictive of a true case-control study. Those papers that satisfied the definition were further evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

RESULTS

The search detected 67 papers that met the inclusion criteria, of which 32 (48%) represented true case-control studies. The frequency of true case-control studies has not changed with time. Use of odds ratios (ORs) and logistic regression (LR) analysis were strong positive predictors of true case-control studies (for odds ratios, OR 15.33 and 95% CI 4.52-51.97; for logistic regression analysis, OR 8.77 and 95% CI 2.69-28.56). Conversely, negative predictors included focus on a procedure/intervention (OR 0.35, 95% CI 0.13-0.998) and use of the word "outcome" in the Results section (OR 0.23, 95% CI 0.082-0.65). After exclusion of nested case-control studies, the negative correlation between focus on a procedure/intervention and true case-control studies was strengthened (OR 0.053, 95% CI 0.0064-0.44). There was a trend toward a negative association between the use of survival analysis or Kaplan-Meier curves and true case-control studies (OR 0.13, 95% CI 0.015-1.12). True case-control studies were no more likely than their counterparts to use a potential study design "expert" (OR 1.50, 95% CI 0.57-3.95). The overall average STROBE score was 72% (range 50-86%). Examples of reporting deficiencies were reporting of bias (28%), missing data (55%), and funding (44%).

CONCLUSIONS

The results of this analysis show that the majority of studies in the neurosurgical literature that identify themselves as "case-control" studies are, in fact, labeled incorrectly. Positive and negative predictors were identified. The authors provide several recommendations that may reverse the incorrect and inappropriate use of the term "case-control" and improve the quality of design and reporting of true case-control studies in neurosurgery.

Risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds in civilian practice

OBJECTIVE

To determine risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds (PCGWs) in civilian practice, in patients who underwent surgery with removal of bullet fragments, wound debridement, and watertight dural closure.

METHODS

An observational, analytical, prospective, cohort-type study was conducted with follow-up in a group of patients with PCGWs caused by a low-velocity projectile admitted between January 2000 and November 2010. There were 160 patients, 59 of whom were administered prophylactic antibiotics based on the decision of the treating neurosurgeon. Average follow-up time was 39 months (range, 3-92 months).

RESULTS

Infection occurred in 40 patients (25%); 20 patients received antibiotics (20 of 59 [33.9%]), and 20 patients did not receive antibiotics (20 of 101 [19.8%]). Three variables were independent risk factors for infection: (i) persistence of parenchymal osseous or metallic fragments after surgery (P < 0.0001, relative risk [RR] 7.45); (ii) projectile trajectory through a natural cavity with contaminating flora (P = 0.03, RR 2.84); and (iii) prolonged hospitalization time (P < 0.0001, RR 3.695).

CONCLUSIONS

Administration of prophylactic antibiotics was not associated with the incidence of intracranial infection secondary to PCGWs. Projectile trajectory through potentially contaminating cavities, persistence of intraparenchymal osseous or metallic fragments after surgery, and prolonged hospital stay were independent risk factors for intracranial infection.

Linezolid treatment of shunt-related cerebrospinal fluid infections in children

OBJECT

The emergence of multidrug-resistant bacteria as a cause of ventriculoperitoneal (VP) shunt infection is a disconcerting phenomenon that often requires the use of alternative antimicrobial agents due to resistance against commonly used medications. Linezolid, a member of a new class of antimicrobial agents, has good activity against virtually all important gram-positive pathogens, including multidrug-resistant gram-positive pathogens. The object of this article is to report a single-center experience with linezolid treatment in 6 young patients with VP shunt infections caused by drug-resistant strains.

METHODS

The authors reviewed the records of 6 pediatric patients who developed VP shunt infection and in whom initial antimicrobial treatment regimens, including vancomycin, either failed or were associated with vancomycin-resistant enterococcus. All 6 patients were treated at their hospital between July 1, 2008, and June 29, 2009. The patients' demographic and clinical characteristics, underlying diseases, clinical manifestations, laboratory results, and various treatment modalities used before linezolid therapy were evaluated.

RESULTS

The 6 patients included were 2 boys and 4 girls with a mean (+/- SD) age of 11.83 +/- 12 months (range 4-36 months). Five patients had acquired an infection within 4 months (mean 7.50 +/- 13.51 months, range 1-35 months) after shunt insertion. Four patients were treated with external ventricular drainage. Two patients' parents refused to allow shunt removal and placement of an external ventricular drain. The CSF was clear of bacterial growth within a mean of 3.67 +/- 1.36 days (range 2-6 days) after initiation of linezolid treatment. The mean duration of linezolid treatment was 18.17 +/- 3.31 days (range 14-21 days). Microbiological clearance of CSF and clinical cure were achieved in all patients. No laboratory or clinical side effects were observed during the treatment period. The mean length of hospital stay was 22.8 +/- 4.96 days (range 17-28 days).

CONCLUSIONS

Linezolid could be an appropriate treatment alternative in children with ventriculostomy-related CSF infections caused by drug-resistant strains, including cases in which shunt removal is not an option. Well-designed prospective studies providing additional information on linezolid levels in plasma and CSF are necessary to confirm the authors' observations.

Multilevel cervical spondylosis

Multilevel cervical spondylosis is a common disorder encountered by most actively practicing spine surgeons. Patients can present with a combination of complaints, including mechanical neck pain, radiculopathy, and myelopathy. A comprehensive evaluation is required for appropriate diagnosis and treatment. Accurate interpretation of imaging techniques, including plain x-rays, CT, and MRI, is necessary to formulate the optimal surgical strategy. Key points to address during construction of the operative plan include the direction of approach, the extent of the decompression, and the type of stabilization construct when necessary. This article outlines various techniques to facilitate operative planning, optimize the surgical objective, and minimize potential complications.

Cerebrospinal fluid shunt infections in children

Infections of cerebrospinal fluid shunts continue to be a substantial source of mortality and morbidity in children with hydrocephalus. Although several therapeutic modalities are currently used for the treatment of shunt infections, there are no clear guidelines for treatment. The purpose of this study was to determine the common pathogens of cerebrospinal fluid shunt infections and evaluate the success of our management. Thirty-five children treated for ventriculoperitoneal shunt infections over the past 9 years were reviewed. The management protocol consisted of the removal of the infected shunt, the application of ventricular taps or reservoir placement, intraventricular antibiotic treatment, and the placement of a new shunt when cerebrospinal fluid sterility was achieved. Four patients were treated with antibiotics alone. Most episodes occurred within 4 months of shunt placement. The most common causative microorganism identified was Staphylococcus epidermidis, followed by S. aureus, and S. warneri. Three patients died from complications of shunt infections, 2 patients had a recurrent shunt infection, while the remaining 29 patients remained free from shunt-related complications. In agreement with the evidence published in the literature, our findings suggest that the above management protocol is effective for the treatment of cerebrospinal fluid shunt infections.

Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis

BACKGROUND

This prospective study aimed to determine the spectrum and the main risk factors of surgical site infection (SSI) after neurosurgical procedures in our clinic.

METHODS

Consecutive patients undergoing neurosurgery between November 1, 2001, and November 1, 2002, were recruited for the study. All patients were followed for a minimum of 2 weeks postoperatively and all SSIs were recorded. The complete medical records of each case were reviewed, and data on 14 possible risk factors were extracted. Statistical analyses were performed to identify the risk factors for SSIs.

RESULTS

A total of 31 postoperative SSIs were identified among 503 cases included in the study, with a resulting overall infection rate of 6.2%. The risk of SSI was increased by age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1; P = .039), operation type such as "shunt operations" (OR, 670.4; 95% CI, 2.6-171123.1; P = .021), presence of foreign body (OR, 141.0; 95% CI, 2.5-7925.9; P = .016), presence of diabetes mellitus (OR, 24.3; 95% CI, 2.1-284.9; P = .011), and intracranial pressure monitoring (OR, 4878.9; 95% CI, 23.8-1001229; P = .002). The predominantly isolated microorganisms in patients with SSIs were Staphylococcus aureus (22 [71.0%]), Acinetobacter baumanii (5 [16.1%]), and Staphylococcus epidermidis (4 [12.9%]).

CONCLUSIONS

SSIs remain an important problem in neurosurgery. Identification of the risk factors for SSI will help physicians to improve patient care and may decrease mortality, morbidity, and health care costs of neurosurgery patients.

A randomized, double-blind comparison of ampicillin/sulbactam and ceftriaxone in the prevention of surgical-site infections after neurosurgery

BACKGROUND

The use of prophylactic antibiotics has been shown to decrease the rate of surgical-site infections after clean neurosurgical operations, although previous clinical trials have provided no evidence that one antibiotic is superior to another for this purpose.

OBJECTIVE

This study was undertaken to compare the rates of postoperative infectious complications of neurosurgery with prophylactic ceftriaxone and ampicillin/sulbactam, a less-expensive antibiotic.

METHODS

Consecutive patients undergoing neurosurgery between January and December 1998 were recruited for the study. Those who had an infectious disease for which antibiotics were required, who received antibiotics within 48 hours before surgery, were aged <12 or >85 years, had an indwelling catheter for the monitoring of intracranial pressure, or had a history of allergy to the study drugs were excluded. Before the operation, eligible patients were randomized to either ampicillin/sulbactam 3 g or ceftriaxone 2 g. Surgeons and patients were blinded to treatment assignment. The study drugs were administered by the anesthesiologist as an IV bolus after induction of general anesthesia. All patients were followed for 6 weeks postoperatively. If reoperation was required within 6 weeks of the original operation, the patient received the same antibiotic as during the first surgery, without further randomization.

RESULTS

Over the 1-year study period, 180 consecutive patients undergoing neurosurgical operations were recruited. Surgical-site infection occurred in 2 (2.3%) patients in the ampicillin/sulbactam group and 3 (3.3%) in the ceftriaxone group; nonsurgical-site infection occurred in 25 (28.4%) patients in the ampicillin/sulbactam group and 15 (16.3%) in the ceftriaxone group. The between-group differences were not statistically significant, with the exception of surgical implantation of foreign material, which was performed sig- nificantly more frequently in the ceftriaxone group (P = 0.045). In addition, 2 of 3 surgical-site infections in the ceftriaxone group involved foreign-material implantation; however, if these operations are omitted from the analysis, the difference between treatments remains nonsignificant.

CONCLUSIONS

The results suggest that ampicillin/sulbactam and ceftriaxone are of similar prophylactic efficacy in clean neurosurgical operations. Because the acquisition cost of 2 g ceftriaxone is approximately 3 times greater than that of 3 g ampicillin/sulbactam, the latter may be more cost-effective than the former for neurosurgical prophylaxis; however, other relevant hospital-related costs were not assessed in this study.

Vancomycin use in pediatric neurosurgery patients

OBJECTIVE

The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use.

METHODS

A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children's Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use.

RESULTS

Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients.

CONCLUSIONS

Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population.

Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence

BACKGROUND

The role of prophylactic antibiotics (PABs) in preventing infections associated with intracranial pressure (ICP) monitors and external ventricular drains (EVD) is not well defined.

METHODS

This study includes an analysis of published reports and a survey of current practices regarding the use of PABs with ICP monitors and EVDs. A computerized data search and a review of the abstracts from two major national neurosurgical meetings over the past decade yielded 85 related articles. Three independent investigators, blinded to the title, author(s), institution(s), results, and conclusions of the articles used predetermined inclusion criteria to select studies for meta-analysis. Thirty-six responses were returned from 98 questionnaires (37%) mailed to university neurosurgical programs.

RESULTS

Among the articles reviewed, only two studies met the predetermined inclusion criteria for the meta-analysis, and they were of insufficient size to produce statistically significant results. Among the 36 programs that responded to the survey, 26 (72%) used PABs, mainly cephalosporins (46%) and semisynthetic penicillins (38%), with ICP monitors and EVDs. Twenty-two (85%) used one drug, and 4 (15%) used two drugs. Twenty-two (61%) of the total group reported intra-institutional variation in practices among individual staff neurosurgeons. Nineteen (53%) expressed interest in a retrospective study, and 27 (75%) expressed interest in a prospective study on the role of PABs in minor neurosurgical procedures.

CONCLUSION

No consensus regarding the use of PABs with ICP monitors and EVDs is noted. Randomized controlled trials of sufficiently large size with appropriate blinding are needed to address this issue.

Infection rate with replacement of bone fragment in compound depressed skull fractures

BACKGROUND

Traditional management of compound depressed skull fractures entails elevation and removal of all bone fragments with delayed cranioplasty. Bone fragment removal is intended to reduce the potential for infection. However, bone fragment removal often necessitates a second operation to repair the resultant calvarial defect. This study examines the postoperative infection rate when bone fragments are replaced primarily.

METHODS

A retrospective study was carried out of all patients admitted with the diagnosis of compound depressed skull fracture to a university hospital from 1991 to 1996.

RESULTS

Of 52 patients with the diagnosis of compound depressed skull fracture treated at our university hospital over the past 5 years, 32 underwent elevation and repair within 72 hours. All patients except one received antibiotics during surgery and for at least 1.5 days after surgery. Follow-up averaged just over 22 months. In all 32 consecutive patients treated with debridement and elevation of compound depressed skull fractures with primary replacement of bone fragments within 72 hours of injury, there were no infectious sequelae.

CONCLUSIONS

Immediate replacement of bone fragments in compound depressed skull fractures does not increase the risk of infectious complications.

Surgical management of patients with severe head injuries

Minutes can make the difference between life and death when patients with severe head injuries require surgery. Subdural, epidural, and intracerebral hematomas and cerebral contusions and gunshot wounds are the pathologic entities encountered most frequently during emergency surgery in patients with severe head injuries. Neurosurgical team members frequently use hyperventilation, mannitol and barbiturates, and sophisticated monitoring modalities to manage patients with severe head injuries during and after surgery. Although monitoring a patient's intracranial pressure (ICP) through a ventriculostomy catheter remains the most widely used gauge of cerebral metabolism, neurosurgical teams also are using fiber-optic ICP monitoring catheters, cerebral blood flow measurement probes, microdialysis catheters, jugular venous oxygen saturation catheters, and brain oxygen content measurement electrodes. Coordinated teamwork by perioperative nurses, neurosurgeons, anesthesia care providers, and emergency department staff members helps ensure the best possible outcomes for patients who require surgery for management of severe head injuries.

Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients

The efficacy of a single dose of cefotiam, a cephalosporin of the second generation, as prophylaxis for postoperative infection was analyzed in a prospective randomized study of 129 patients undergoing cerebrospinal fluid shunting. The main focus of interest was the rate of shunt infection requiring operative shunt removal. Data were evaluated in the total group and subgroups formed for normal and high risk patients, respectively. The overall rate of shunt infection was 7.5% in the cefotiam group and 12.9% in the control group. In the high risk subgroup infection rate was 14.3% with and 26.3% without cefotiam as opposed to 4.3% and 6.9%, respectively, in the normal risk subgroup. Although our results do not reach statistical significance, there is a noticeable difference of infection rate between those patients who receive the antibiotic and those who do not. Therefore, we favor single dose antibiotic prophylaxis in shunting procedures.

Efficacy of prophylactic antibiotics for craniotomy: a meta-analysis

A meta-analysis of published randomized studies comparing prophylactic antibiotics to placebo in craniotomies was performed. Ten studies were examined; eight met criteria for inclusion into the meta-analysis. The analysis showed an advantage of antibiotics over placebo at the P < 10-8 level. Tests for homogeneity of effect size between the individual studies showed similar effects of antibiotic treatment between trials, despite variation in the randomization methods and antibiotic regimens used. No statistically significant difference was detected between antibiotic regimens that did or did not cover gram-negative organisms or between single- and multiple-dose regimens. Cumulative meta-analyses showed that this conclusion could have been confidently drawn by 1988, after only four of the eight eligible trials had been published. Trials published since that time have reinforced these conclusions but have not significantly altered them. Future studies should compare proposed new antibiotic regimens with one of those already demonstrated to be effective, not with a placebo.

Ceftizoxime versus vancomycin and gentamicin in neurosurgical prophylaxis: a randomized, prospective, blinded clinical study

In a prospective, randomized, blinded study, 826 patients undergoing clean neurosurgical procedures received single intravenous doses of ceftizoxime (2 g) (n = 422) or a combination of vancomycin (1 g) and gentamicin (80 mg) (n = 404) 1 hour before an incision was made. Patients with infected or contaminated wounds and those receiving shunts or other implants were excluded. Primary wound infections occurred within 30 days in five patients in each group and were most common after spinal surgery and procedures through previous incisions. Secondary infections (pneumonias, urinary tract infections, and intravenous line-related bacteremia) occurred in 24 patients in the ceftizoxime group and 25 in the vancomycin/gentamicin group. The infection rates after transsphenoidal procedures (n = 129) were remarkably low in both groups. Ceftizoxime caused no adverse drug reactions, but six patients in the vancomycin/gentamicin group had clinically significant infusion-related hypotension or flushing. Placement of a temporary external drain, use of an operating microscope, preoperative steroids, and diabetes were not associated with increased infection rates. Analysis of routinely encountered ventricular cerebrospinal fluid and simultaneously obtained peripheral blood showed low but detectable levels of all three antibiotics within 2 hours; only ceftizoxime, however, achieved cerebrospinal fluid levels sufficient to inhibit the staphylococcus and Gram-negative bacilli most often associated with postneurosurgical infections. We conclude that ceftizoxime is as effective as vancomycin and gentamicin in neurosurgical prophylaxis but is less toxic and penetrates cerebrospinal fluid better.

Prophylactic use of antimicrobial agents in adult patients

The prophylactic use of antimicrobial agents is recommended for prevention of numerous infections, including tuberculosis, endocarditis, rheumatic fever, recurrent cellulitis and lymphangitis in patients with lymphedema, meningococcal meningitis, and bite wounds. In addition, the prophylactic use of antimicrobial agents has proved effective in certain surgical procedures such as various abdominal operations, hysterectomy, and major operations that involve the head and neck. Except for oral bowel preparations, antimicrobial prophylaxis should be limited, in general, to the operative period. Prolonged perioperative prophylaxis has not been shown to enhance effectiveness and may result in increased toxicity, resistant superinfections, and inflated costs. The investigation of antimicrobial prophylaxis necessitates adequate evaluation of the potential advantages and disadvantages in a prospective, double-blind fashion.

Intra-operative antibiotic prophylaxis in neurosurgery. A prospective, randomized, controlled study on cefotiam

In this prospective, randomized and controlled study the effect of cefotiam for the prevention of wound infections following trepanations was investigated. The main interest was centered on the rate of post-operative bone flap infections requiring operative revision. Administration of cefotiam was randomized for patients undergoing major craniotomies. The antibiotic was administered intravenously in a single dose of 2 g with induction of anaesthesia. Only clean or clean contaminated cases were included. Excluded were contaminated cases, operations with a transnasal-transsphenoidal approach, shunt-operations and patients with any other preoperative infection or antibiotic therapy. Outpatients were excluded due to difficulties in obtaining sufficient clinical information. From originally 918 consecutive patients operated on 711 fulfilled the entry criteria. With regard to age, sex, diagnosis and the site of te trepanation, control patients (n = 355) and cefotiam treated patients (n = 356) were shown to be comparable. In the various subgroups formed for different primary diagnoses, concomitant steroidal therapy and concomitant severe internal medical diseases cefotiam treated patients and controls were comparable as well. A highly significant difference for bone flap infection could be shown with 0.3% in the cefotiam group versus 5.1% in the control group (p less than 0.001). The overall rate of post-operative deep wound infections including meningitis and abscesses was also significantly (p less than 0.005) different with 3.1% in the cefotiam versus 9.0% in the control group. Thus it was concluded that a single dose of cefotiam significantly reduces post-operative deep wound infection.

Antibiotic prophylaxis during prolonged clean neurosurgery. Results of a randomized double-blind study using oxacillin

The efficacy of oxacillin as a prophylaxis for infection was analyzed in a 27-month randomized double-blind study of 400 patients who had undergone clean neurosurgical interventions lasting longer than 2 hours. Four neurosurgeons took part in the study and 356 patients were eligible for final analysis. Among the 171 patients treated with oxacillin, there was one case of infection (0.6%), compared to nine (4.9%) of the 185 patients given a placebo. The difference between the two groups was statistically significant (p = 0.0398). This study, together with others (randomized or not), clearly demonstrates the efficacy of antibiotic prophylaxis in prolonged clean neurosurgery.