Infections In Neurosurgery Research Articles

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.

633. Incidence, Microbial Etiology and Antibiotic Resistance Patterns with Special Reference to Shunt Infections in Neurosurgery at a Tertiary Center in North India

BackgroundVentriculoperitoneal (VP) shunt is one of the commonest procedures in neurosurgical practice. A significant problem encountered in shunt procedures is infection, with infection rate ranging from 2 to 27%, often with poor outcome. The objectives of the study were to retrospectively evaluate the infection rate associated with central nervous system (CNS) shunts, assess the frequency of the pathogens as well as their antibiotic sensitivity pattern to aim at suitable prophylaxis.MethodsMaterials and Methods. Retrospective study conducted in the Microbiology Department, SGPGI, Lucknow from December 2017 to August 2018. A total of 168 CSF samples were received with a suspected shunt infection. Samples were analyzed by wet mount, India ink, gram stain and inoculated on blood agar and MacConkey agar. Identification and AST were done by MALDI- TOF system (VITEK-MS) and Vitek 2.0 automated sensitivity system.ResultsDuring the study period, 37/168(22.02%) CSF were positive by culture. Most frequently isolated pathogen was Acinetobacter baumannii 20/37(54.05%), followed by Staphylococcus aureus 06/37 (16.20%), Enterococcus faecalis 04/37(10.81%) coagulase negative staphylococci- CONS 04/37(10.81%), Klebsiella pneumoniae 2/37 (5.40%)and Escherichia coli 1/37(2.70%). 100% of A. baumannii and E. coli strains were found to be XDR and carbapenem-resistant showing susceptibility to minocycline and colistin only. All strains of K.pneumoniae were MDR. 66.7% S.aureus were MRSA and showed 100% resistance to fluoroquinolone. A similar pattern was seen in CONS. 25% of Enterococci were found to be vancomycin resistant.ConclusionDiscussion and Conclusion. The antibiotic sensitivity pattern suggests aminoglycosides, colistin and vancomycin to be a better choice of antibiotics either prophylactically/therapeutically, which may result in effective sterilization of the CSF. Infections following VP shunt procedure are secondary to catheter blockage complicating the results of surgery and are associated with high morbidity and mortality rates.Disclosures All authors: No reported disclosures.

Impact of Powdered Vancomycin on Preventing Surgical Site Infections in Neurosurgery: A Systematic Review and Meta-analysis.

Surgical site infections (SSIs) after spine and brain surgery present a major burden to patients and hospitals by increasing morbidity, mortality, and healthcare costs. To review available literature investigating the role of intrawound powdered vancomycin against SSIs after neurosurgical operations. All randomized and observational English language studies of intrawound powdered vancomycin use in spinal and cranial surgery were included and analyzed using random-effects modeling. In spine surgery (25 studies with 16 369 patients), patients in the vancomycin group had a significantly lower risk for any SSI (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.30-0.57; P<.001; I2 = 47%). However, when separate analyses were conducted for superficial and deep SSIs, a significant difference was found only for deep (OR: 0.31; 95% CI: 0.22-0.45; P<.001; I2 = 29%). Subgroup analyses for different vancomycin powder dosages (1 g vs 2 g vs composite dose) did not point to any dose-related effect of vancomycin. In cranial surgery (6 studies with 1777 patients), use of vancomycin was associated with a significantly lower risk for SSIs (OR: 0.33; 95% CI: 0.18-0.60; P = .0003; I2 = 45%). In meta-regression analysis, trial-level variability of diabetes had no influence on the association of vancomycin powder use with SSIs. Use of vancomycin powder in spinal and cranial surgery might be protective against SSIs, especially against deep SSIs. No dose-related effect of vancomycin powder was identified. However, caution is needed in the clinical interpretation of these results, owing to the observational design of the included studies in this meta-analysis.

Risk factors for surgical site infections in neurosurgery.

Surgical site infections (SSIs) are of profound significance in neurosurgical departments, resulting in high morbidity and mortality. There are limited public data regarding the incidence of SSIs in neurosurgery. The aim of this study was to determine the rate of SSIs (particularly those requiring reoperation) over a seven-year period and identify factors leading to an increased risk. An age matched retrospective analysis was undertaken of a series of 16,513 patients at a single centre. All patients who required reoperation for suspected SSIs within a 7-year period were identified. Exclusion criteria comprised absence of infective material intraoperatively and patients presenting with primary infections. Clinical notes were reviewed to confirm presence or absence of suspected risk factors. Of the 16,513 patients in the study, 1.20% required at least one further operation to treat a SSI. Wound leak (odds ratio [OR]: 27.41), dexamethasone use (OR: 3.55), instrumentation (OR: 2.74) and operative duration >180 minutes (OR: 1.85) were statistically significant risk factors for reoperation. This is the first UK study of such a duration that has documented a SSI reoperation rate in a cohort of this size. Various risk factors are associated with the development of SSIs, making it essential to have robust auditing and monitoring of high risk patients to ensure excellent standards of healthcare. Departmental and public registers to record all SSIs may be beneficial, particularly for those treated solely by general practitioners, allowing units to address potential risk factors prior to surgical intervention.

2143. Incidence of Infection in Patients Receiving Short vs. Long Duration of Antimicrobial Prophylaxis in Neurosurgery

BackgroundSurgical site infections in neurosurgery occur in up to 10% of procedures. The American Society of Health-System Pharmacists guidelines promote antimicrobial prophylaxis (AP) for up to 24 hours from neurosurgery using cefazolin while the Neurocritical Care Society guidelines promote single pre-procedural dose of AP for extraventricular drain (EVD) monitoring. Despite these guidelines, practice variation exists with often longer antimicrobial exposure and subsequent complications.MethodsThis retrospective study included patients admitted to Baylor University Medical Center from January 1, 2014 to September 20, 2017 and underwent cranial or spinal neurosurgery requiring AP. This study excluded patients with basilar skull fracture, presence of cerebrospinal fluid leak, penetrating trauma, meningitis, and patients receiving antibiotics for documented or suspected infection unrelated to neurosurgery. Patients who received AP for up to 24H (short course) were compared with patients who received AP for greater than 24H (long course) at 90 days. Data were analyzed using the Fisher exact test, Student’s t-test and Wilcoxon rank-sum tests as applicable.ResultsA total of 183 patients were included with 90 and 93 patients receiving short or long courses of AP, respectively. Baseline characteristics were similar for the groups. Patients in the short course AP group received a mean antibiotic duration of 16.9 ± 4.3H while those in the long course AP group received 72.2 ± 50.9H (P < 0.001). The mean number of antimicrobials prescribed was 1.1 vs. 1.8 (P < 0.001) in the short vs. long groups, respectively. At 90 days, there were no significant differences in the rate of surgical site infections (1.1% vs. 2.1%, P = 0.99), development of multi-drug-resistant infections (2.2% vs. 2.2%, P = 0.99), and Clostridium difficile infection (0% vs. 1.1%, P = 0.99) in the short vs. long groups, respectively.ConclusionThe rate of surgical site infections was not significantly different in patients that received short vs. long durations of antimicrobial prophylaxis. These results highlight an opportunity to improve antibiotic use and promote principles of antimicrobial stewardship in neurosurgery.Disclosures All authors: No reported disclosures.

Effect of implementing infection control guidelines on minimizing surgical wound infection for patients undergoing neurosurgery

Background and objective: Nursing role delivered at all levels of care is critical to eliminate surgical wound infection after neurosurgery. Aim: Evaluate the effect of implementing infection control guidelines on minimizing surgical wound infection for patients undergoing neurosurgery.Methods: Pretest/posttest was used to assess and evaluate nurses' practices pre and post implementation of infection control guidelines while posttest only was used for patients to evaluate the effect of implementing infection control guidelines on minimizing surgical wound infection. Thirty-six nurses in neurosurgery department at Assiut Neurological, Psychiatric and Neurosurgery University Hospital, also 443 patients undergoing neurosurgery were included. Nurses' practices were assessed pre and post implementation of infection control guidelines. Tools: Nurses' observation checklist, patients’ assessment sheet, patients’ follow up sheet and neurosurgery infection control guidelines (teaching booklet) for nurses. Results: Nurses’ practices were improved, infection in neurosurgery was eradicated according to results of environmental swabs and surgical wound infection was reduced post implementation of infection control guidelines.Conclusion and recommendation: Proper implementation of disinfection and sterilization enhance safe and effective care. Infection control policy should be developed in neurosurgery department and all healthcare team should be responsible to adhere and implement it.

Book Review: Atlas of Infections in Neurosurgery and Spinal Surgery

Book Review: Atlas of Infections in Neurosurgery and Spinal Surgery

Evaluation of a micro/nanofluidic chip platform for the high-throughput detection of bacteria and their antibiotic resistance genes in post-neurosurgical meningitis

BackgroundPost-neurosurgical meningitis (PNM) is one of the most severe hospital-acquired infections worldwide, and a large number of pathogens, especially those possessing multi-resistance genes, are related to these infections. Existing methods for detecting bacteria and measuring their response to antibiotics lack sensitivity and stability, and laboratory-based detection methods are inconvenient, requiring at least 24h to complete. Rapid identification of bacteria and the determination of their susceptibility to antibiotics are urgently needed, in order to combat the emergence of multi-resistant bacterial strains. MethodsThis study evaluated a novel, fast, and easy-to-use micro/nanofluidic chip platform (MNCP), which overcomes the difficulties of diagnosing bacterial infections in neurosurgery. This platform can identify 10 genus or species targets and 13 genetic resistance determinants within 1h, and it is very simple to operate.A total of 108 bacterium-containing cerebrospinal fluid (CSF) cultures were tested using the MNCP for the identification of bacteria and determinants of genetic resistance. The results were compared to those obtained with conventional identification and antimicrobial susceptibility testing methods. ResultsFor the 108 CSF cultures, the concordance rate between the MNCP and the conventional identification method was 94.44%; six species attained 100% consistency. For the production of carbapenemase- and extended-spectrum beta-lactamase (ESBL)-related antibiotic resistance genes, both the sensitivity and specificity of the MNCP tests were high (>90.0%) and could fully meet the requirements of clinical diagnosis. ConclusionsThe MNCP is fast, accurate, and easy to use, and has great clinical potential in the treatment of post-neurosurgical meningitis.

A. Akhaddar (ed): Atlas of Infections in Neurosurgery and Spinal Surgery

A. Akhaddar (ed): Atlas of Infections in Neurosurgery and Spinal Surgery

Topical vancomycin to reduce surgical-site infections in neurosurgery: Study protocol for a multi-center, randomized controlled trial

Surgical-site infections (SSIs) account for 20% of all healthcare-associated infections, are the most common nosocomial infection among surgical patients, and are a focus of quality improvement initiatives. Despite implementation of many quality care measures (e.g. prophylactic antibiotics), SSIs remain a significant cause of morbidity, mortality, and economic burden, particularly in the field of neurosurgery. Topical vancomycin is increasingly utilized in instrumented spinal and cardiothoracic procedures, where it has been shown to reduce the risk of SSIs. However, a randomized controlled trial assessing its efficacy in the general neurosurgical population has yet to be done.The principle aim of “Topical Vancomycin for Neurosurgery Wound Prophylaxis” (NCT02284126) is to determine whether prophylactic, topical vancomycin reduces the risk of SSIs in the adult neurosurgical population. This prospective, multicenter, patient-blinded, randomized controlled trial will enroll patients to receive the standard of care plus topical vancomycin, or the standard of care alone. The primary endpoint of this study is a SSI by postoperative day (POD) 30. Patients must be over 18years of age. Patients are excluded for renal insufficiency, vancomycin allergy, and some ineligible procedures. Univariate analysis and logistic regression will determine the effect of topical vancomycin on SSIs at 30days.A randomized controlled trial is needed to determine the efficacy of this treatment. Results of this trial are expected to directly influence the standard of care and prevention of SSIs in neurosurgical patients.

Clinical significance and cut-off value of the infection of coagulase-negative staphylococcus obtained from cerebrospinal fluid specimens in neurosurgical patients

Objective To study on the contribution and cut-off value of coagulase negative staphylococcus (CoNS) in laboratory tests of postoperative infection in neurosurgery and optimize the diagnostic criteria of infection. Methods It made a retrospective study of 650 cerebrospinal fluid (CSF) specimens from neurosurgical patients, who were infected CoNS in Beijing Tiantan Hospital affiliated to Capital Medical University during 2013-2015. The epidemiological data were collected and 8 routine clinical laboratory tests were performed. T test was used to compare the difference among the groups. By making receiver operating characteristic (ROC) curve, the area under the curve (AUC), cut-off value, sensitivity and specificity were obtained. Results A total of 19 756 CSF specimens were collected and 650 CoNS were isolated. The separation rate of CoNS was 3.3% which was the most frequently isolated bacteria. The differences of cerebrospinal fluid white blood cell count(3 598.6±1 884.3, 678.1±629.1, t=2.662, P=0.012), multinucleated cell ratio in cerebrospinal fluid(76.0±32.6, 46.8±29.9, t=9.593, P=0.001), cerebrospinal fluid glucose concentration(5.9±2.12, 6.2±1.92, t=-16.296, P=0.001) and cerebrospinal fluid glucose concentration/blood glucose concentration (0.3±0.16, 0.63±0.31, t=-11.968, P=0.000) among groups were statistically significant. The AUCs of cerebrospinal fluid white blood cell count, cerebrospinal fluid glucose and cerebrospinal fluid glucose/blood glucose were more than 0.8, and the sensitivities of the three indicators were more than 80.0%. In addition, the specificity of cerebrospinal fluid glucose concentration/blood glucose concentration was more than 0.9. Conclusions CoNS was the main pathogenic bacteria of neurosurgical infections in a hospital. Cerebrospinal fluid white blood cell count, cerebrospinal fluid glucose and the ratio of cerebrospinal fluid glucose and blood glucose could be used for auxiliary diagnosis of CoNS infections in neurosurgical patients.(Chin J Lab Med, 2017, 40: 707-710) Key words: Cerebrospinal fluid; Neurosurgical infection; Coagulase-negative staphylococcus; Receiver operating curve

Reducing Surgical Site Infections in Neurosurgery: A Multidisciplinary Approach

Reducing Surgical Site Infections in Neurosurgery: A Multidisciplinary Approach

Operative Duration and Risk of Surgical Site Infection in Neurosurgery

The association of surgical duration with the risk of surgical site infection (SSI) has not been quantified in neurosurgery. We investigated the association of operative duration in neurosurgical procedures with the incidence of SSI. We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. To control for confounding, we used multivariable regression models and propensity score conditioning. During the study period there were 94,744 patients who underwent a neurosurgical procedure and met the inclusion criteria. Of these patients, 4.1% developed a postoperative SSI within 30 days. Multivariable logistic regression showed an association between longer operative duration with higher incidence of SSI (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20). Compared with procedures of moderate duration (third quintile, 40th-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 2.07; 95% CI, 1.86-2.31) of developing SSI. The shortest procedures (<20th percentile) were associated with decreased incidence of SSI (OR, 0.72; 95% CI, 0.61-0.83) compared with those of moderate duration. The same associations were present in propensity score adjusted models and models stratified by subgroups of cranial, spinal, peripheral nerve, and carotid procedures. In a cohort of patients from a national prospective surgical registry, longer operative duration was associated with increased incidence of SSI for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management and to stratify patients with regard to SSI risk.

Nosocomial bloodstream infections in neurosurgery: a 10-year analysis in a center with high antimicrobial drug-resistance prevalence

Data on nosocomial bloodstream infections (NBSI) in neurosurgery is limited. This study aimed to analyze the epidemiology, microbiology, outcome, and risk factors for death in neurosurgical patients with NBSI in a multidrug resistant setting. Neurosurgical patients with a confirmed NBSI within the period 2003-2012 were retrospectively analyzed. NBSI was diagnosed when a pathogen was isolated from a blood sample obtained after the first 48h of hospitalization. Patients' demographic, clinical, and microbiological data were recorded and analyzed using univariate and multivariate analysis. A total of 236 patients with NBSI were identified and 378 isolates were recovered from blood cultures. Incidence of NBSI was 4.3 infections/1000 bed-days. Gram-negative bacteria slightly predominated (54.5%). The commonest bacteria were coagulase-negative staphylococci (CoNS, 26%), Klebsiella pneumoniae (15.3%), Pseudomonas aeruginosa (14.8%), and Acinetobacter baumannii (13.2%). Carbapenem resistance was found in 90% of A. baumannii, in 66% of P. aeruginosa, and in 22% (2003-2007) to 77% (2008-2012) of K. pneumoniae isolates (p < 0.05). Most CoNS and Staphylococcus aureus isolates (94 and 80%, respectively) were methicillin-resistant. All Gram-negative isolates were sensitive to colistin and all Gram-positive isolates were sensitive to vancomycin and linezolid. Antimicrobial consumption decreased after 2007 (p < 0.05). Overall mortality was 50.4%. In multivariate analysis, advanced age and stay in an Intermediate Care Unit (IMCU) were independent risk factors for in-hospital mortality (p < 0.05). Overall, high incidence of NBSI and considerable resistance of Gram-positive and particularly Gram-negative bacteria were noted in neurosurgical patients. Mortality was high with advanced age and stay in IMCU being the most important death-related factors.

Strategies for reducing surgical site infection in neurosurgery: experience from a Brazilian hospital

Our Hospital focus on providing excellent care for surgical patients, with approximately 9000 surgeries happening in our Operating Rooms (OR) every year.

Fatores de risco de infecção da ferida operatória em neurocirurgia

Objetivo Analisar os fatores de risco de infecção da ferida operatória em neurocirurgia. Métodos Estudo transversal, prospectivo, conduzido em hospital de nível terciário com 85 neurocirurgias eletivas e limpas, tendo como desfecho a infecção até 30 dias após o procedimento cirúrgico. Resultados A ocorrência de infecção de sítio cirúrgico foi de 9,4% (n=8). Na análise bivariada observou-se que os fatores de risco: tempo total de internação, Índice de Massa Corporal, porte cirúrgico e transfusão sanguínea foram associados com a presença de infecção. Após ajuste no modelo de regressão logística binária, apenas o tempo total de internação mostrou relação estatisticamente significativa com a presença de infecção. Conclusão A ocorrência de infecção de sítio cirúrgico em neurocirurgia na instituição estudada foi maior do que o preconizado na literatura científica. Os resultados apontaram que o acompanhamento ambulatorial do paciente cirúrgico após a alta hospitalar pode reduzir a subnotificação dos casos de infecção.

Infections postopératoires dans le service de neurochirurgie à l'hôpital Gabriel Touré

postoperative infection in neurosurgery is one of the dreaded complications that may compromise the results of the surgery.The objectives of this study were to find the factors favoring infection and germs responsible.This was a retrospective study of 12 months between January 2009 and December 2009 in the Department of Neurosurgery at the Gabriel Toure hospital. It involved all infections within three months after surgery. The average age of patients was 30.3 years with a male predominance. The mean operating time was 149 minutes 41 seconds . All patients received antibiotics in made intraoperatively and continued for two days.. Infections appeared before the Flanker postoperative week. All infections have involved the surgical site for 13 patients and were fresh purulent and serous purulent 3 cases . Infections were found in 62.5 % (12 patients) before the tenth day and 37.5% between the 11th and 20th day. After the sample of the abscess analysis to the laboratory, a DST was conducted for all germs, Escherichia coli and Staphylococcus aureus were the most frequently encountered microorganisms (56.25%).. The evolution was marked by one death. Postoperative infection is one of the complications that can affect the results of the surgery on the one hand but also to lengthen the duration of hospitalization with financial implications. Its occurred is the result of several factors, including the lack of respect of asepsis rules.

Effectiveness and Cost of Failure Mode and Effects Analysis Methodology to Reduce Neurosurgical Site Infections

Mercy Hospital Springfield is a tertiary care facility with 32 000 discharges and 15 000 inpatient surgeries in 2011. From June 2009 through January 2011, a stable inpatient elective neurosurgery infection rate of 2.15% was observed. The failure mode and effects analysis (FMEA) methodology to reduce inpatient neurosurgery infections was utilized. Following FMEA implementation, overall elective neurosurgery infection rates were reduced to 1.51% and sustained through May 2012. Compared with baseline, the post-FMEA deep-space and organ infection rate was reduced by 41% (P = .052). Overall hospital inpatient clean surgery infection rates for the same time frame did not decrease to the same extent, suggesting a specific effect of the FMEA. The study team believes that the FMEA interventions resulted in 14 fewer expected infections, $270 270 in savings, a 168-day reduction in expected length of stay, and 22 fewer readmissions. Given the serious morbidity and cost of health care-associated infections, the study team concludes that FMEA implementation was clinically cost-effective.

Preoperative shaving does not reduce infection in neurosurgery

Preoperative shaving does not reduce infection in neurosurgery

A single centre audit into the outcome of transsphenoidal surgery in the treatment of acromegaly

A single centre audit into the outcome of transsphenoidal surgery in the treatment of acromegaly