Choice of Antibiotics in the

prophylaxis and Treatment of

ommon Neurosurgical Problems
Chayooth Thanapornsangsuth
Fifth year medical student
Pathogenesis of surgical site infection
 Invasive potential of bacteria or other pathogens
that are inoculated into wound during surgery
that exceeds the capability of local and systemic
host defense
 >105 Increase potential of SSI
 Presence of foreign material (ex. VP shunt)

decrease size of minimal inoculation

 Gram positive bacteria biofilms shield

pathogen, inhibit action of antibiotics

 Primary reservoir=flora colonizing the skin and

paranasal sinuses
Risk Factors
 Patients characteristics associated with surgical site of
infection
 1. Concomitant remote site infection eg. pneumonia,
UTIs
 2. DM
 3. Cigarette smoking
 4. Prolonged use of systemic corticosteroids
 5. Obesity
 6. Extreme age
 7. Poor nutritional status
 8. Others eg. U/D malignancies, use of
immunosuppressive agents in organ transplant patients
Classification of wounds and
predictors of surgical site infection
 Predict degree of microbial contamination at
a surgical site and likelihood of developing a
surgical site of infection(SSI)
Classification of surgical wounds
Wound Classification Definition Examples
Clean An uninfected wound Lumbar diskectomy
Respiratory, GI, GU tract not encountered Temporal lobectomy
Wound closed primarily
May be drained with closed drainage
system

Clean contaminated Respiratory, GI, GU tract entered under Transsphenoidal pituitary

controlled conditions Retromastoid craniectomy for
No usual contamination microvascular decompression
Acute open depressed skull
fracture

Contaminated-open Acute accidental wounds

Major violation of sterile technique
Gross contamination from GI tract
Nonpurulent inflammation may present

Dirty/infected-old Traumatic wounds with retained

devitalized tissue
Purulent tissue encountered
Perforation of major viscera
Independent risk factors associated with development
of surgical site infection(SSI) <SENIC project>

 1. Intraabdominal procedure
 2. Operation greater than 2 hours
 3. Wound classified as contaminated or dirty
 4. Operation performed on patients having

greater than three discharge diagnoses

Antimicrobial prophylaxis
 Definition
 1. Prophylaxis- ATB administration for

procedures with minimal contamination of

surgical site anticipated
 2. Therapy- ATB administration for

procedures with significant contamination

 Techniques for surgical prophylaxis CDC
Recommendations for Prevention of SSI

Category Definition
IA Strongly recommended for all hospitals and strongly supported by well-
designed experimental or epidemiological studies

IB Strongly recommended for all hospitals and viewed as effective by experts in

field and a consensus of Hospital Infection Control Practices Advisory
Committee (HICPAC) based on strong rationale and suggestive evidence,
even though definitive scientific studies may not have been done

II Suggested for implementation in many hospitals

Recommendations may be supported by suggestive clinical
recommendations or epidemiological studies, a strong theoretical rationale,
or definitive studies applicable to some but not all hospitals.
No Practices for which insufficient evidence or no consensus regarding efficacy
recommendation;
unresolved issue exists
CDC Guidelines for the use of
Prophylactic ATB
 The prophylactic antimicrobial agent should
be efficacious against the most common
pathogens causing SSI for a specific
operation(IA); for neurosurgery, this mandate
excellent gram positive coverage against
most common skin contaminants such as
staphylococcal species and attention to the
organism predominant in the surgeon
institution
CDC Guidelines for the use of
Prophylactic ATB
 The ATB should ideally be administered
intravenous within 30 minutes but not longer
than 2 hours before the initial incision(IA)
 Administer of the prophylactic antimicrobial

agent as close as possible to the time of

induction of anesthesia(II)
 Prophylaxis should not be extended to the

time of postoperative period(IB)

CDC Guidelines for the use of
Prophylactic ATB
 Additional intraoperative doses should be
considered (a) during procedures whose
duration exceeds the estimated half-life of
the drug, (b) during operations associated
with major blood loss, (c) during operations
on morbidly obese patients (IB)
 Vancomycin should not be administered

routinely for category IB

Considerations
 1. Prophylactic ATB is not risk free
 -Vancomycin hypotensive episodes or

flushing
 -Aminoglycosides Ototoxicity
 -Penicillin 8% of patient suffer adverse

reactions
 2. Costs
Clinical Data regarding antimicrobial
prophylaxis
 1. Clean neurosurgical procedures
 2. Foreign body implantation
 3. Timing and duration of prophylaxis
 4. Prophylactic ATB in patient with basilar

skull fractures
 5. Prophylactic ATB for external ventricular

drains
Clean neurosurgical procedures
 Clean procedures Efficacy established
 Clean contaminated General surgical

procedures have clearly been shown to

benefit from preoperative ATB
 Dirty and contaminated cases Therapeutic

rather than prophylactic

Foreign body implantation
 For CSF shunt, the higher the baseline
infection rate of CSF procedure, the more
protective prophylactic ATB appeared to be. If
the baseline infection rate <5% use other
method of infection control such as rigorous
aseptic technique
Foreign body implantation
 Other foreign bodies eg. Intrathecal catheter,
synthetic cranioplasties, deep brain and
spinal cord electrodes, no controlled trial
regarding the efficacy of prophylactic
antibiotics.
Timing and duration of prophylaxis
 Timing- with in 2 hours of incision time
 Duration- procedures whose length exceeds

the half life of the prophylactic ATB repeat

dose
Prophylactic ATB in patient with
basilar skull fractures
 No convincing data that supports the
prophylactic use of ATB
 1. Routine use of ATB will lead to resistance

of more virulent organism than would

otherwise be encountered
 2. CSF analysis may fail to identify organism
 3. Problem relating toxicity
Prophylactic ATB for external
ventricular drains
 External ventricular drains are used to
monitor intracranial pressure and therapeutic
drainage of CSF
 Lumbar subarachnoid drains management

of CSF leaks + administration of intrathecal

medications
Prophylactic ATB for external
ventricular drains
 No clear evidence that this is beneficial
 Other than prophylactic ATP, other steps that

are important are strict aseptic technique

during placement, tunneling of catheter away
from insertion site, minimal entry into the
system, changing catheter at specified
interval.
Antibiotic Therapy of Neurosurgical
Infections
 1. Posttraumatic and postoperative bacterial
meningitis
 2. Post operative bone flap infection, cranial

epidural abscess, and subdural emphysemas

 3. Bacterial Brain abscess
Posttraumatic and postoperative
bacterial meningitis
 Majority is caused by secondary complication
of basilar skull fracture and CSF fistulae
 Fracture of skull base + tearing of dura

direct communication with paranasal sinuses,

mastoid air cels bacteria ingress to
subarachnoid space
 Strep. pnemoniae + other Strep.spp about

three-quarters of cases
 Secondary bacterial meningitis  Same ATB

treatment with that occurs spontaneously

 Post operative bone flap infection, cranial
epidural abscess, and subdural emphysemas

 Post operative bone flap infection- uncommon

-diagnosis- fever, pain, tenderness, erythema,
swelling, fluctuance, drainage of purulent
material from the incision
-risk factors- procedure of long duration,
reoperation, trauma, exposure involving the air
sinuses, poor irradiation of the scalp, use of
foreign body drain, immunosuppression,
excessive traffic in and out of the surgical
suite.
 Post operative bone flap infection, cranial
epidural abscess, and subdural emphysemas

 Treatment
 - if not ill-appearing or toxic wait until

cultures are obtained

 - appears ill or manifest systemic signs of

toxicity ATB start without delay

 Staphylococcus aureus accounts for most

cases
Cranial epidural abscess
 Stapphylococci account for most
postoperative infection
 Many other organisms can be encounted with

CEA
 Initial empiric therapy should be broad

spectrum
 Parenteral ATB should be given 4-6 weeks
Subdural Empyema
 ATB similar to as above
 In infants complication of bacterial meningitis

most commonly due to Haemophilus

influenzae. In such case ampicillin or
cefuroxime can be used with third generation
cephalosporins as alternative agents
Bacterial Brain abscess
 1. Empiric therapy should be based on a
thorough understanding of the
microbiological flora that is anticipated based
on individual clinical situation
 2. Treatment should be adequate
 3. Therapy should be adjusted as necessary

based on cultures