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

Performance of a Large Language Model in the Generation of Clinical Guidelines for Antibiotic Prophylaxis in Spine Surgery

OBJECTIVE

Large language models, such as chat generative pre-trained transformer (ChatGPT), have great potential for streamlining medical processes and assisting physicians in clinical decision-making. This study aimed to assess the potential of ChatGPT's 2 models (GPT-3.5 and GPT-4.0) to support clinical decision-making by comparing its responses for antibiotic prophylaxis in spine surgery to accepted clinical guidelines.

METHODS

ChatGPT models were prompted with questions from the North American Spine Society (NASS) Evidence-based Clinical Guidelines for Multidisciplinary Spine Care for Antibiotic Prophylaxis in Spine Surgery (2013). Its responses were then compared and assessed for accuracy.

RESULTS

Of the 16 NASS guideline questions concerning antibiotic prophylaxis, 10 responses (62.5%) were accurate in ChatGPT's GPT-3.5 model and 13 (81%) were accurate in GPT-4.0. Twenty-five percent of GPT-3.5 answers were deemed as overly confident while 62.5% of GPT-4.0 answers directly used the NASS guideline as evidence for its response.

CONCLUSION

ChatGPT demonstrated an impressive ability to accurately answer clinical questions. GPT-3.5 model's performance was limited by its tendency to give overly confident responses and its inability to identify the most significant elements in its responses. GPT-4.0 model's responses had higher accuracy and cited the NASS guideline as direct evidence many times. While GPT-4.0 is still far from perfect, it has shown an exceptional ability to extract the most relevant research available compared to GPT-3.5. Thus, while ChatGPT has shown far-reaching potential, scrutiny should still be exercised regarding its clinical use at this time.

A Systematic Review of Studies Reporting Antibiotic Pharmacokinetic Data in the Cerebrospinal Fluid of Critically Ill Patients with Uninflamed Meninges

Ventriculostomy-associated infections in critically ill patients remain therapeutically challenging because of drug- and disease-related factors that contribute to suboptimal antibiotic concentrations in cerebrospinal fluid. Optimal antibiotic dosing for the treatment and prevention of such infections should be based on robust and contextually specific pharmacokinetic data. The objects of this study were to describe and critically appraise studies with reported antibiotic concentrations or pharmacokinetic data in cerebrospinal fluid of critically ill patients without meningeal inflammation. We systematically reviewed the literature to identify published reports and studies describing antibiotic concentrations, pharmacokinetics, and pharmacokinetics/pharmacodynamics in cerebrospinal fluid of critically ill patients with uninflamed meninges. Fifty-eight articles met the inclusion criteria. There was significant heterogeneity in methodologies and results. When available, antibiotic pharmacokinetic parameters displayed large intersubject variability. Intraventricular dosing achieved substantially higher antibiotic concentrations in cerebrospinal fluid than did intravenous doses. Few studies conducted a robust pharmacokinetic analysis and described relevant clinical pharmacokinetic/pharmacodynamic indices and exposure targets in cerebrospinal fluid. Robust and clinically relevant antibiotic pharmacokinetic data describing antibiotic disposition in cerebrospinal fluid are necessary. Such studies should use a standardized approach to accurately describe pharmacokinetic variability. These data should ideally be tied to clinical outcomes whereby therapeutic targets in the cerebrospinal fluid can be better defined. Altered dosing strategies, in conjunction with exploring the utility of therapeutic drug monitoring, can then be developed to optimize antibiotic exposure with the goal of improving outcomes in this difficult-to-treat patient group.

Adverse effects of a single dose of gentamicin in adults: a systematic review

AIMS

To systematically review the frequency and type of adverse events associated with a single dose of intravenous or intramuscular gentamicin in adults, for any indication, in studies where a comparator was available.

METHODS

A review protocol was developed and registered (PROSPERO: CRD42013003229). Studies were eligible for review if they: recruited participants aged ≥16 years; used gentamicin intramuscularly or intravenously as a single one-off dose; compared gentamicin to another medication or placebo; and monitored adverse events. MEDLINE, EMBASE, Cochrane Library, trial registries, conference proceedings and other relevant databases were searched up to November 2016. Risk of bias was assessed on all included studies.

RESULTS

In total, 15 522 records were identified. After removal of duplicates, screening of title/abstracts for relevance and independent selection of full texts by two reviewers, 36 studies were included. Across all the included studies, 24 107 participants received a single one-off dose of gentamicin (doses ranged from 1 mg kg^-1 to 480 mg per dose). Acute kidney injury was described in 2520 participants receiving gentamicin. The large majority of cases were reversible. There were no cases of ototoxicity reported in patients receiving gentamicin. A meta-analysis was not performed due to study heterogeneity.

CONCLUSIONS

A significant number of patients saw a transient rise in creatinine after a single dose of gentamicin at doses up to 480 mg. Persistent renal impairment and other adverse events were relatively rare.

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.

Efficacy of ultra-short single agent regimen antibiotic chemo-prophylaxis in reducing the risk of meningitis in patients undergoing endoscopic endonasal transsphenoidal surgery

OBJECTIVES

The study aims to evaluate the incidence of infectious complications (namely meningitis) within 30 days after endoscopic endonasal transspheinodal neurosurgery (EETS) in patients receiving an ultra-short peri-operative chemo-prophylaxis regimen with 2 doses of 1st generation cephalosporin or macrolide.

PATIENTS AND METHODS

We retrospectively analyzed the clinical records of 145 patients who received an ultra-short chemoprophylaxis with two doses of an antibiotic, given 30 min before and 8h after EETS, over a 30-month time-frame. Ninety-seven patients (66.89%) received endovenous cefazolin, a 1st generation cephalosporin, administered at a dosage of 1000 mg, and 48 patients (33.10%) with an history of allergy to various agents, received endovenous clarithromycin at a dosage of 500 mg.

RESULTS

No case of peri- and post-operative meningitis occurred in patients receiving the 2 doses of antibiotic. Only one patient (0.68%) developed cerebral fluid leakage on the 7th postoperative day, which required the switching to a broad-spectrum antibiotic prophylaxis for one week; this patient received the ultrashort prophylaxis with a macrolide. In addition, 7 patients (4.82%) developed minor infectious complications such as low-grade fever (3 cases, all of them receiving cefazolin), enlarged submandibular and cervical lymphnodes (3 cases, all of them receiving cefazolin), and upper and lower respiratory tract infection (1 case receiving clarithromycin). The cost of this prophylaxis regimen ranged from 7.76 Euro (cefazolin) to 39.54 Euro (clarithromycin).

CONCLUSIONS

This study suggested that an ultra-short single-antibiotic prophylaxis is a safe, cheap and effective regimen to prevent post-operative meningitis in patients undergoing EETS and who do not require lumbar drainage after surgery. In these patients also the rate of minor infective complications was acceptable when compared with the previous more expensive regimen based on 3rd generation cephalosporin plus aminoglycoside or alone, that could be suitable only for at-risk patients (e.g. smokers, cerebrospinal leak or Cushing's diseases).

An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

PURPOSE

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

CONCLUSIONS

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

External ventricular drainage for intraventricular hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Glycopeptide vs. non-glycopeptide antibiotics for prophylaxis of surgical site infections: a systematic review

BACKGROUND

Patients receive prophylactic antibiotics against surgical site infections (SSIs) before or during many procedures. Glycopeptide antibiotics are effective against most strains of methicillin-resistant Staphylococcus aureus (MRSA), but their wider use risks increasing resistance. Our objective was to review the evidence for clinical effectiveness that might help to determine whether there is a threshold of MRSA prevalence at which switching from non-glycopeptide to glycopeptide antibiotic prophylaxis might be justified.

METHODS

We performed a systematic review of randomized trials comparing a glycopeptide with an alternative antibiotic regimen for SSI prophylaxis in adults undergoing clean or clean-contaminated surgical procedures. The evidence was used to inform development of a decision-analytic model. We subsequently updated the review to May 2008.

RESULTS

Fourteen studies were identified that provided evidence concerning clinical effectiveness. The studies were too heterogeneous clinically for meta-analysis. Only one of 12 trials found that glycopeptides reduced SSIs significantly at 30 days compared with non-glycopeptide antibiotics. Of the two trials that reported on MRSA infection, neither found a significant difference between glycopeptide and comparator drugs.

CONCLUSIONS

This systematic review did not find any evidence to support the use of glycopeptides in preference to other antibiotics for the prevention of MRSA infections and SSIs. The limitations of the evidence make it difficult to identify a threshold at which a switch from non-glycopeptide to glycopeptide prophylaxis should be recommended. Given the difficulties of addressing this issue through randomized trials, further research should focus on hospital infection control policies, MRSA screening, and the isolation and treatment of anyone infected with MRSA prior to surgery.

Association between Asymptomatic Urinary Tract Infection and Postoperative Spine Infection in Elderly Women : A Retrospective Analysis Study

OBJECTIVE

The purpose of this study is to identify the relationship between asymptomatic urinary tract infection (aUTI) and postoperative spine infection.

METHODS

A retrospective review was done in 355 women more than 65 years old who had undergone laminectomy and/or discectomy, and spinal fusion, between January 2004 and December 2008. Previously postulated risk factors (i.e., instrumentation, diabetes, prior corticosteroid therapy, previous spinal surgery, and smoking) were investigated. Furthermore, we added aUTI that was not previously considered.

RESULTS

Among 355 patients, 42 met the criteria for aUTI (Bacteriuria >/= 10(5) CFU/mL and no associated symptoms). A postoperative spine infection was evident in 15 of 355 patients. Of the previously described risk factors, multi-levels (p < 0.05), instrumentation (p < 0.05) and diabetes (p < 0.05) were proven risk factors, whereas aUTI (p > 0.05) was not statistically significant. However, aUTI with Foley catheterization was statistically significant when Foley catheterization was added as a variable to the all existing risk factors.

CONCLUSION

aUTI is not rare in elderly women admitted to the hospital for lumbar spine surgery. The results of this study suggest that aUTI with Foley catheterization may be considered a risk factor for postoperative spine infection in elderly women. Therefore, we would consider treating aUTI before operating on elderly women who will need Foley catheterization.

Positive nasal culture of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infection in orthopedics

BACKGROUND

Although nasal carriage of MRSA has been identified as one of the risk factors for surgical site infection (SSI) with MRSA, there have been no reports of this in the orthopedics field.

METHODS

This prospective observational cohort study included 2,423 consecutive patients who were admitted to our department over 26 months and who underwent orthopedic surgery. We examined the relationship between pre-existing nasal MRSA and subsequent occurrence of SSI with MRSA.

RESULTS

63 patients (2.6%) had a positive nasal MRSA culture. 15 patients (0.6%) developed SSI with MRSA. The occurrence of SSI with MRSA in nasal MRSA carriers was significantly higher than that in non-carriers (4 out of 63 (6.3%) vs. 11 out of 2,360 (0.5%); p < 0.001) (adjusted OR: 11; 95% CI: 3-37; p = 0.001).

INTERPRETATION

We recommend appropriate treatment of patients who are nasal carriers of MRSA before orthopedic surgery.

Retrospective analysis of a new antibiotic chemoprophylaxis regimen in 170 patients undergoing endoscopic endonasal transsphenoidal surgery

BACKGROUND

The aim of this study is to evaluate the rate of infectious complications post endoscopic transspheinodal neurosurgery in patients receiving a new antibiotic chemoprophylaxis regimen.

METHODS

Clinical records of 170 patients who received prophylaxis with a third-generation cephalosporin plus aminoglycoside (160 cases) or alone (10 cases) were retrospectively analyzed. Twenty-eight patients (16.4%) had CSF leakage. The postsurgical follow-up ranged from 3 months to 4 years.

RESULTS

Of 170 patients, 2 (1.17%) developed infectious complications: 1 case of meningitis by Staphylococcus epidermidis and 1 case of sphenoid sinusitis (without microbiological diagnosis). In addition, asymptomatic sphenoid sinusitis was diagnosed in 2 other patients. The cost ranged from 22.50 to 33.34 euros/d.

CONCLUSIONS

The rate of infectious complications was very low in patients receiving prophylaxis with a third-generation cephalosporin plus aminoglycoside or alone; because of the broad-spectrum of antibiotics and their high cost, this regimen could be used in at-risk patients (eg, smokers, patients with cerebrospinal leak, or patients with Cushing diseases).

Management of perioperative infectious complications in the neurologic patient

Although most neurosurgeries are considered "sterile" procedures, anti-biotic prophylaxis is favored in the literature because of the potential for serious complications related to the central nervous system. There is a paucity of literature addressing the management of infectious complications related to neurostimulators and intraspinal/epidural catheters and pump; therefore, further studies are needed to develop standard protocols of care. Finally, perioperative complications in the patient undergoing a neuro-surgical procedure are similar to those undergoing any surgery, but have a higher potential for morbidity and mortality because of the central nervous system. The skill of the surgeon, care of the perioperative team, and knowledge of the neurologist remain the most important factors in the prevention, early recognition, and intervention of these complications.

Cefazolin prophylaxis in neurosurgery monitored by capillary electrophoresis

Prophylactic use of antibiotics to prevent postoperative infections is a routine method in neurosurgery. Little is known about the period of effectiveness of antibiotics applied only for the purposes of operation. The actual concentration of cefazolin was determined in the serum, in the contents of wound drains, and in the cerebrospinal fluid in a 24-hour postoperative period after the administration of 1 g of cefazolin just prior to skin incision in 8 patients undergoing lumbar discectomy and 11 patients undergoing craniectomy. The concentration of the antibiotic was then compared with the minimal inhibitory concentration values of cefazolin for 10 different bacterial species. For evaluating the concentration of cefazolin, capillary electrophoresis was used, which is a new clinical application of this separation technique. Results showed that the antibiotic was effective against bacterial breeding in the serum and in the drainage up to 12 hours. The drug concentration in the cerebrospinal fluid remained less than the value of the serum, and it exceeded the minimal inhibitory concentration values only for approximately 5 hours.

Risk factors for surgical site infection in spinal surgery

OBJECT

The objective of this study was to identify specific independent risk factors for surgical site infections (SSIs) occurring after laminectomy or spinal fusion.

METHODS

The authors performed a retrospective case-control study of data obtained in patients between 1996 and 1999 who had undergone laminectomy and/or spinal fusion. Forty-one patients with SSI or meningitis were identified, and data were compared with those acquired in 178 uninfected control patients. Risk factors for SSI were determined using univariate analyses and multivariate logistic regression. The spinal surgery-related SSI rate (incisional and organ space) during the 4-year study period was 2.8%. Independent risk factors for SSI identified by multivariate analysis were postoperative incontinence (odds ratio [OR] 8.2, 95% confidence interval [CI] 2.9-22.8), posterior approach (OR 8.2, 95% CI 2-33.5), procedure for tumor resection (OR 6.2, 95% CI 1.7-22.3), and morbid obesity (OR 5.2, 95% CI 1.9-14.2). In patients with SSI the postoperative hospital length of stay was significantly longer than that in uninfected patients (median 6 and 3 days, respectively; p < 0.001) and were readmitted to the hospital for a median additional 6 days for treatment of their infection. Repeated surgery due to the infection was required in the majority (73%) of infected patients.

CONCLUSIONS

Postoperative incontinence, posterior approach, surgery for tumor resection, and morbid obesity were independent risk factors predictive of SSI following spinal surgery. Interventions to reduce the risk for these potentially devastating infections need to be developed.

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.

Short-term antibiotic prophylaxis for the prevention of wound infection and secondary meningitis in acoustic neuroma surgery: a ten-year experience in a regional hospital

Wound infection and secondary meningitis are important complications for patients undergoing acoustic neuroma surgery. The Authors retrospectively evaluated the efficacy of a short-term protocol utilizing vancomycin and netilmicin. 434 patients underwent acoustic neuroma surgery in the Otorhinolaryngology Division, A.O. Ospedali Riuniti di Bergamo, from February 1987 to February 1997. Perioperative short-term prophylaxis was administered with vancomycin plus netilmicin. The utility of the prophylaxis schedule was evaluated on the basis of the occurrence of infectious episodes during the first 10-day follow-up. Only 2 episodes (0.5%) of bacterial meningitis were observed.

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.

Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee

EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie

Topical irrigation with polymyxin and bacitracin for spinal surgery

BACKGROUND

The purpose of the present study was to evaluate constant irrigation with saline containing 50,000 units each of polymyxin and bacitracin in a regimen of antimicrobial prophylaxis for clean spinal surgery at two community hospitals with a zero infection rate.

METHODS

The focus was on the bactericidal effects of prophylactic topical antibiotics by assessing random contamination in neurosurgical wounds from: 1) the flora of the integument and nares of the operating team, 2) the surgical apparel, 3) the patient's skin, 4) air-borne organisms in the operating theater, and 5) the surgeon's gloves.

RESULTS

Based on individual biotyping of bacteria and antimicrobial sensitivity testing, no consistent source or pattern could be uncovered for the organisms recovered from the operative site. Relying on longitudinal data, the incidence of intraoperative bacterial growth with continuous saline lavage was reduced from 64 to 4% when the combination of topical polymyxin and bacitracin was added.

CONCLUSIONS

Although the virtual elimination of bacterial growth in the surgical site was accomplished, the efficacy of topical antibiotics in the prevention of wound infection remains unproven.

Chryseobacterium meningosepticum: an emerging pathogen among immunocompromised adults. Report of 6 cases and literature review

Chryseobacterium meningosepticum is a ubiquitous Gram-negative bacillus historically associated with meningitis in premature neonates. We report 15 positive cultures and 6 cases of infection among immunocompromised adults at our institution over a 10-year period and review the English-language literature on C. meningosepticum. Excluding the present series, there are 308 reports of positive cultures in the literature, of which 59% were determined to represent true infections. Sixty-five percent of those infected were younger than 3 months of age. Meningitis was the most common infectious syndrome among neonates, seen in 84% of cases and associated with a 57% mortality rate. Less commonly reported infections among infants included sepsis (13%) and pneumonia (3%). Pneumonia was the most frequent infection among the postneonatal group, accounting for 40% of cases, followed by sepsis (24%), meningitis (18%), endocarditis (3%), cellulitis (3%), abdominal infections (3%), eye infections (3%), and single case reports of sinusitis, bronchitis, and epididymitis. The 6 cases in our series were all adults, with a mean age of 58.7 years. Sites of C. meningosepticum infection were limited to the lungs, bloodstream, and biliary tree. Infection in our series was associated with prolonged hospitalization, prior exposure to multiple antibiotics, and host immunocompromise, particularly neutropenia. C. meningosepticum is resistant to multiple antibiotics, and disk dilution is notoriously unreliable for antibiotic sensitivity testing. Sensitivity testing on the 15 isolates from our institution revealed the most efficacious antibiotics to be minocycline (100% sensitive), rifampin (93%), trimethoprim-sulfamethoxazole (67%), and ciprofloxacin (53%). In contrast to reports in the literature, the isolates in our series displayed widespread resistance to vancomycin (100% resistant or intermediately sensitive), erythromycin (100%), and clindamycin (86%). These findings have important implications for the clinician when choosing empiric antibiotic regimens for patients with risk factors for C. meningosepticum infection.