Management of perioperative infectious complications in the neurologic patient

In neurosurgical interventions, the high morbidity and mortality and seriousness of potential complications may lead to devastating and fatal outcomes as a result of meningitis, osteomyelitis, brain abscesses, and device infections. The gold standard of care, as with all surgeries, remains excellent surgical skills and techniques that involve the entire operating room team. There are few randomized, placebo-controlled clinical trials addressing the need for perioperative antibiotic prophylaxis for neurosurgical procedures for infection prevention; however, the current literature advocates their use, although most of these procedures are considered "sterile." The use of these agents remains controversial; however, with infectious complications causing increased patient morbidity, they probably are justified. There seems to be a specific role for prophylaxis in procedures that are considered "clean-contaminated," such as extirpation of a brain abscess, entry through the sinuses, or the implant of foreign devices or materials [1]. According to Voth's review [1], skull procedures may have up to a 3% to 5% infection rate, spinal procedures a rate of 7.6%, and surgery of the peripheral nerves and vertebral column an infection rate similar to that of orthopedic surgeries. Infectious risks associated with skull procedures are related to osteomyelitis of the bone flap and infections of the subdural space. The choice of antibiotic prophylaxis for the prevention of infections depends mainly on the type of procedure, the microbial ecology of the surgical site, and the sensitivity of the pathogens isolated according to each institution, specifically the intensive care units. Risk for infection increases with age, malnutrition, other ongoing infections, metabolic abnormalities, and medically unresolved issues. Neurosurgical patients taking high-dosage preoperative dexamethasone or those who have implanted synthetic materials or devices are at a higher risk for perioperative complications. Although currently there is no recommended standard regimen for antibiotic prophylaxis in neurosurgical procedures, it still is advocated in the current literature and the majority of institutions. The decision to administer perioperative prophylaxis, however, is left mainly to the surgeon. Currently, there are no comparative studies determining the superiority of one protocol over another. There is a consensus that the optimal regimen must be active against Staphylococcus aureus and other gram positive bacteria that make up 80% of the pathogens isolated [2]. Therefore, a regimen of vancomycin and gentamycin or tobramycin, with or without gentamycin, or streptomycin irrigation fluid [3,4] or a first- or second-generation cephalosporins [2], single-dose and repeated intraoperatively every 3 hours for 24 hours postoperatively, is advocated. Follow-up studies are required to determine if cerebrospinal fluid (CSF) penetration is an important factor for prophylaxis, as most antibiotics have poor penetration when administered systemically. Aternative protocols for antibiotic regimen prophylaxis are summarized in Table 1. Most neurosurgeons discriminately employ routine prophylaxis favored by the current literature to cover gram-positive skin bacteria. More uniform study protocols are needed, however, to determine if this option is superior to giving no prophylaxis, to determine the true standard of care.