David KriegerMarch 26, 2010

Rates of craniotomy and cranioplasty infections• Evidence for increasing rates

Pathogen causes for infectionsLiterature review of Causes of Infection• Modifiable risk factors

Ways to combat pathogens• Antibiotics

Reported rate of infection between 0.5%-10 % in larger studies

Raggueneau et al. (Neurochirurgie 1983) 5.1 %• 1000 patients, retrospective study

Mollman et al. (J Neurosurg 1986) 1.1%• 9202 patients, retrospective study

Korinek et al. (Neurosurgery 1997) 4%• 2944 patients, prospective study

Korinek et al. (Neurosurgery 2006) 8.8% and 4.6%• 6243 patients, prospective study

Mclleland et al. (Clin Infect Dis 2007) 0.8%• 2111 patients, retrospective study• Elective cases

Dashti et al. (Neurosurg Focus 2008) 0.5%• 16,540, retrospective study• Only included re-operative cases

Wound infections, bone flap osteitis, meningitis, and brain abscesses (Korinek et al.)

Meningitis, epidural abscess, subdural empyema, brain abscess, bone‐flap infection, and/or wound infection (Mclleland et al.)

Bone flap infection, subdural empyema, or cerebral abscess…require a repeated operation (Dashti et al.)

Inamasu et al. J Trauma 2010

Year Infections

N= Rate

2006 34 687 4.95%

2007 31 772 4.02%

2008 43 846 5.08%

2009 42 714 5.88%

Source: Dr. Phyllis Flomenberg and Infection Control

Year Infections

N= Rate

2007 7 70 10.0%

2008 13 78 16.6%

2009 16 72 22.0%

Year Infections

N= Rate

2004 39 385 10.12%

2005 13 324 4.01%

2006 3 306 0.98%

2007 5 316 1.58%

2008 2 303 0.66%

2009 3 270 1.11%

Determined by Infection Control Same auditor for the last 6 years• Decrease likelihood of measurement bias• Lower rates of infection prior to this auditor

Hardware monitored for 365 days Positive infection:• Positive culture • Home on IV ABX even without positive culture

DASHTI ET AL. KORINEK ET AL. (2006)

Korinek et al. 2006

Cranioplasty SSIs do not correlate with positive bone flaps

50 % are CONS

0% are MRSA

Cranioplasty SSI Organisms 2009

“Emergency surgery, opening of the sinus, presence of a foreign body, and operation lasting more than 5 hours” (Ragguenea et al.)

“Postoperative cerebrospinal fluid leakage, subsequent operation, emergency surgery, clean-contaminated and dirty surgery, an operative time longer than 4 hours, and recent neurosurgery” (Korinek et al. 1997)

“Antibiotic prophylaxis reduced incision infections … but did not prevent meningitis”(Korinek et al.)

Length of Case Time

Antibiotics

Korinek et al. 1997

YEAR AVG CUT TO CLOSE (MINS)

AVG IN ROOM TO OUT ROOM (MINS)

2006 217.70 321.09

2007 221.48 321.36

2008 215.30 314.70

2009 202.80 308.07

2010 179.16 271.44

Source: ORSOS, Maria Ricci, Information Systems

Year Number of People / Case

2006 8.48

2007 8.96

2008 9.23

2009 9.25

Timing

Type of Antibiotic

Timing: Before or After or Both• Prospective Randomized Controlled Trial, n=1708

• “….patients who received the prophylactic antibiotics preoperatively, 0.6 percent subsequently had surgical-wound infections… of 488 patients who received the antibiotics postoperatively 3.3 percent had wound infections (P less than 0.0001) …of 369 patients who had antibiotics administered early, 3.8 percent had wound infections (P less than 0.0001)… logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection.”

Classen et al. NEJM 1992

Retrospective Review of 34,000 medicare inpatients“An antimicrobial dose was administered to 55.7% of patients within 1 hour before incision.”

Bratzler et al. Arch Surg 2005

Antimicrobial agents consistent with published guidelines were administered to 92.6% of the patients. Antimicrobial prophylaxis was discontinued within 24 hours of surgery end time for only 40.7%”“CONCLUSION: Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.”

56 hospitals tried simple improvement measures of timing of antibiotics (Table 3)

1 2 3 4 P(1 vs 4)

Antibiotic within 1 hr

72 82 89 92 <0.001

Appropriate antibioic selection

90 94 95 95 0.02

Discontinue within 24 hrs

67 69 74 85 <0.001

Dellinger et al. Am J Surg 2005

Single prophylactic dose for surgeries less than 4 hours and no major blood loss

Repeat dosing every 1-2 half lives• Ancef every 2-5 hrs• Vanc every 6-12 hrs• Clinda every 3-6 hrs

Discontinued within 24 hrs (Bratzler and Houck Clin Infect Dis 2004 and Treat Guid Med Lett)

No evidence that repeat dosing past surgery is effective (McDonald et al, Aust J Surg 1998, review of 28 prospective, randomly controlled trials)

Randomized Prospective Trial, single institution, 846 patients, preop or intraop, clean surgeries

Antibiotics: Ancef or Gentamicin

“An analysis of subgroups of surgical procedures revealed a dramatic decrease in craniotomy infections from 6.77% to 0% (p = 0.003)”

Prospective, randomized and controlled study the effect of cefotiam for the prevention of wound infections, n=661

Bone flap infection 0.3% versus 5.1% (p < 0.001)

Overall post-operative 3.1% versus 9.0% (p< 0.005)

The OR method estimated a final OR of a

6243 craniotomies, prospective, multicenter, clean and contaminated surgeries

Antibiotics: Cloxacillin

No effect on meningitis (1.63% vs. 1.50%), primary endpoint

“Antibiotic prophylaxis reduced incision infections from 8.8% down to 4.6% (P<0.0001)…although clearly effective for the prevention of incision infections, does not prevent meningitis and tends to select prophylaxis resistant microorganisms”

Study Study Size Study Type Antibotic Decrease Infection

Ragguenea et al. (1983)

1000 Retrospective/Single Institution

Variable Only for cases >5 hrs

Mollman et al. (1986)

9202 Retrospective/Single Institution

Variable Yes (decrease by 20%)

Korinek et al. (1997)

2944 Prospective/Multicenter

Variable Not significant

Korinek et al. (2005)

4578 Prospective/Multicenter

Cloxacillin/Clinda

Yes (9.7 to 5.8%)

Korinek et al. (2006)

6243 Prospective/Multicenter

Cloxacillin/Clinda

Yes (8.8 to 4.6 %)

Ancef 1 g or 2 g IV

OR Vancomycin• Previous colonization with MRSA• Hospitals in which MRSA or CONS are common• Allergy to PCN or cephalosporin

Clindamycin to replace vanco for patients with beta-lactam allergy (600-900 mg)

Pros: High rates of MRSA infection (cranioplasty)

Cons: needs to be given as 1 hr infusion prior to surgery, less effective against MSSA

Evidence: • Bolon et al. (Clin Infect Dis 2004): Meta-analysis of

cardiac surgery patients shows no advantage (7 randomized controlled trials)

• Tacconelli et al. (J Hosp Infect 2008): Prospective, randomized controlled trial of VP shunts shows benefit in hospital with high rate of MRSA

Muciprocin/Body Scrub

Cranioplasty Storage Methods

Skin Disinfection

Cochrane Review (2008): Nine randomized controlled trials showing that muciprocin reduced Staph infection in carriers (but not in surgical cases)

NEJM (2010): Randomized, double blind placebo-controlled trial, n=6771

PCR analysis of nasal swabs for MRSA

Nasal ointment applied twice daily and the soap was used daily for a total-body wash. The duration of the study treatment was 5 days

Inamasu et al. J Trauma 2010

Prospective, randomized, multicenter trial, n=849

Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05)

Darouiche et al. NEJM 2010

>97 % Povidone Iodine

Chloraprep in 0.2%

Caveat to NEJM study, in addition:• Alcohol in 8% of cases• Duraprep (Iodine Povacrylex and Isopropyl

Alcohol, 74%) in 51.5% of cases

No infections for 2010

Differences?• Awareness• ????

Antimicrobial prophylaxis for surgery. Treat Guide Med Lett 2009; 7:47. Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box AT, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010 Jan 7;362(1):9-17.Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis. 2004 May 15;38(10):1357-63.Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: anadvisory statement from the National Surgical Infection Prevention Project. Surgical Infection Prevention Guidelines Writers Workgroup. Clin Infect Dis. 2004 Jun 15;38(12):1706-15. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma A, Carr K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005 Feb;140(2):174-82.

Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992 Jan 30;326(5):281-6.Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH.Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. N Engl J Med. 2010 Jan 7;362(1):18-26.Dashti SR, Baharvahdat H, Spetzler RF, Sauvageau E, Chang SW, Stiefel MF, Park MS, Bambakidis NC. Operative intracranial infection following craniotomy. Neurosurg Focus. 2008;24(6):E10.Dellinger EP, Hausmann SM, Bratzler DW, Johnson RM, Daniel DM, Bunt KM, Baumgardner GA, Sugarman JR. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005 Jul;190(1):9-15.Inamasu J, Kuramae T, Nakatsukasa M. Does difference in the storage method of bone flaps after decompressive craniectomy affect the incidence of surgical site infection after cranioplasty? Comparison between subcutaneous pocket and cryopreservation. J Trauma. 2010Jan;68(1):183-7.

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