Category: Infections

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Efficacy of Vancomycin Powder Prophylaxis in 987 Cranial Surgeries for Nonmalignant Pathology

Neurosurgery 98:1076–1084, 2026

This study evaluates whether prophylactic subgaleal vancomycin powder reduces surgical site infections (SSIs) after 987 craniotomies for nonmalignant pathology. In a retrospective cohort (682 with vancomycin, 305 without), overall SSI incidence was very low and did not differ significantly between groups, with six infections recorded and diverse cultured pathogens.

The authors contrast prior studies biased toward malignant, high-risk populations, discuss potential harms of indiscriminate vancomycin use (resistance, wound complications), and recommend a more selective, evidence-based application while calling for larger multicenter research to define high-risk subgroups and dosing effects.

Objective Assess whether prophylactic subgaleal vancomycin powder reduces surgical site infections (SSI) in nonmalignant cranial surgeries.

Design Retrospective chart review of 987 nonmalignant cranial surgeries (July 2021–June 2024), comparing vancomycin powder (n=682) vs no vancomycin powder (n=305).

Intervention Vancomycin cohort received 1 g powder applied over the bone flap before galeal closure; all patients received standard IV cefazolin, chlorhexidine prep, and postoperative incisional bacitracin.

Primary outcome SSI incidence was not significantly different: 0.3% without vancomycin vs 0.7% with vancomycin (P = .578), with 6 total infections.

SSI distribution Infections occurred mainly with atypical meningiomas (3/6) and schwannomas (2/6), plus 1 amoebic abscess case.

Pathogens 7 pathogens were cultured from 6 SSI cases; Cutibacterium acnes was most common (3/6), and Klebsiella aerogenes occurred in 2 vancomycin cases (vancomycin-resistant).

Interpretation Routine prophylactic vancomycin powder in nonmalignant cranial surgery may be unnecessary given the very low SSI rate and lack of demonstrated benefit.

Caveats Retrospective design with potential selection bias and only 6 SSI events; larger/multicenter studies are needed to identify any high-risk subgroups who might benefit.

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Prevention of Ommaya Reservoir–Associated Bacterial Meningitis With Prophylactic Intraventricular Vancomycin

Neurosurgery 98:643–650, 2026

This clinical cohort study evaluates prophylactic intraventricular vancomycin (10 mg added to each intraventricular chemotherapy cycle) to prevent Ommaya reservoir–associated bacterial meningitis in patients with leptomeningeal disease. Over 501 treatments in 63 patients, infection rate was 0% versus 10.25% in a 5-year historical control, with no observed vancomycin toxicity and substantial cost savings.

The manuscript details methods, statistical analyses, safety monitoring, limitations inherent to a historical-control design, and a meta-analytic context of prior infection rates. Authors conclude prophylactic intraventricular vancomycin eliminated infections in their cohort and recommend consideration of broader adoption and prospective randomized trials.

Prophylactic intraventricular vancomycin: Adding 10 mg of intraventricular vancomycin to each cycle of planned intrathecal chemotherapy through an Ommaya reservoir (OmR) in patients with leptomeningeal disease eliminated OmR-associated bacterial meningitis infections over a 12-month period (0% infection rate in 63 patients, 501 treatments).

Historical infection rates: Prior to vancomycin prophylaxis, OmR-associated infection rates were 10.25% per patient and 1.71% per treatment in a 5-year historical control group (322 patients, 1932 treatments).

Absolute risk reduction and NNT: The absolute risk reduction for OmR-associated infection was 10.3% (P = .0028), with a number needed to treat (NNT) of 10 to prevent one infection.

No observed toxicity or resistance: No vancomycin-associated toxicity or development of antibiotic-resistant infections was observed during the study period, even with repeated dosing.

Significant cost savings: Prophylactic vancomycin cost $10 per dose, with an estimated annual savings of over $600,000 by preventing infections and associated treatments, not including potential additional savings from avoiding reservoir removal and replacement.

Robust methodology: The intervention was implemented as a global practice change, with prospective data collection for the vancomycin cohort and comparison to a well-matched historical control group, though some differences in tumor type and number of treatments existed.

Clinical and practical implications: The findings support strong consideration of prophylactic intraventricular vancomycin in OmR-based chemotherapy regimens, with the potential to significantly improve patient outcomes and reduce healthcare costs.

Need for further research: Prospective randomized trials are recommended to confirm these results and establish optimal dosing and broader applicability.

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Intraoperative vancomycin for preventing infection after open spine surgery: a systematic review and meta-analysis of randomized controlled trials

J Neurosurg Spine 43:509–518, 2025

A meta-analysis of seven randomized controlled trials found that intraoperative vancomycin use in open spine surgery did not significantly reduce rates of superficial or deep surgical site infections. Further large-scale studies are needed to clarify its efficacy and inform clinical guidelines.

• A systematic review and meta-analysis of 7 randomized controlled trials (RCTs) with 2235 patients assessed the efficacy of intraoperative vancomycin in preventing infections after open spine surgery.

• No significant reduction in overall surgical site infections (SSI), deep infections, or superficial infections was found with intraoperative vancomycin compared to control.

• Subgroup analyses showed no benefit in either instrumented or uninstrumented spine surgeries.

• There was no significant shift toward gram-negative or culture-negative infections with vancomycin use.

• Potential risks include local cytotoxicity and possible impairment of bone healing and spinal fusion.

• Current evidence is limited by small sample sizes, heterogeneity in vancomycin administration, and variable follow-up durations.

• The study concludes intraoperative vancomycin may not reduce infection risk and further large RCTs are warranted.

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Incidence, Management, and Outcomes of Pediatric Infectious Aneurysms

Operative Neurosurgery 29:27–33, 2025

This retrospective study reviews five pediatric cases of infectious intracranial aneurysms (IIAs) secondary to infective endocarditis. IIAs in children are rare but have high morbidity and mortality, with early surgical or endovascular intervention recommended due to frequent failure of medical management and high rerupture rates.

• Pediatric infectious intracranial aneurysms (IIAs) are rare complications, most often secondary to infective endocarditis (IE), and account for 2–14% of pediatric intracranial aneurysms.

• This retrospective study identified 5 pediatric cases of IIA among 151 children treated for IE (3%), with most patients having congenital or acquired heart disease.

• The majority (80%) presented with ruptured aneurysms causing subarachnoid hemorrhage (SAH); one was found incidentally.

• All patients were started on antibiotics, but 80% failed medical management and required surgical or endovascular intervention.

• Mortality was high: 2 of 5 patients (40%) died within a year, and only 2 survivors had good neurological outcomes (mRS <2).

• Early intervention (surgical or endovascular) is recommended for ruptured IIAs due to high rates of rerupture and medical management failure.

• A multidisciplinary approach is essential for optimal outcomes in these complex cases.

• Further studies with larger cohorts are needed to determine the best management strategies.

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Use of Patient-Specific Interbody Cages Through a Minimally Invasive Lateral Approach for Unstable Lumbar Spondylodiskitis

Operative Neurosurgery 28:59–68, 2025

Patients with diskitis/osteomyelitis who do not respond to medical treatment or develop spinal instability/deformity may warrant surgical intervention. Irregular bony destruction due to the infection can pose a challenge for spinal reconstruction. The authors report a lateral approach using patient-specific interbody cages combined with posterior or lateral instrumentation to achieve spinal reconstruction for spinal instability/deformity from spondylodiskitis.

METHODS: This is a retrospective review of 4 cases undergoing debridement, lateral lumbar interbody fusion using patient-specific interbody cages, and supplemental lateral or posterior instrumentation for spinal instability/deformity after spondylodiskitis. The surgical technique is reported, as are the clinical and imaging outcomes.

RESULTS: Four male patients with a mean age of 69 years comprised this study. One had lateral lumbar interbody fusion at L2/3 and 3 at L4/5. The mean hospital stay was 5.8 days. The mean follow-up was 8.5 months (range 6-12 months). There were no approach-related neurological injuries or complications. The mean visual analog scale back pain scores improved from 9.5 to 1.5, and the mean Oswestry disability index improved from 68.5 to 23 at the end of the follow-up. The mean lumbar lordosis increased from 18°to 51°. The segmental angle increased from 6.5°to 18°. The coronal shift was 2.8 cm preoperatively and 0.9 cm postoperatively. The coronal Cobb angle reduced from 8.8°preoperatively to 2.8°postoperatively. On postoperative computed tomography, all patients had interval development of bridging bone across the surgical level through or around the cage. None of them developed cage migration or subsidence.

CONCLUSION: Patients with irregular bony destruction due to diskitis/osteomyelitis may benefit from patient-specific cages for spinal reconstruction to address spinal instability and deformity.

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Antibiotic-Impregnated Ventriculoperitoneal Shunts Decrease Bacterial Shunt Infection: A Systematic Review and Meta-Analysis

Neurosurgery 95:1263–1273, 2024

Antibiotic-impregnated shunts seem to be beneficial in preventing bacterial infections and decreasing mortality by effectively inhibiting microbial growth in the shunt system and reducing the risk of shunt-associated infections. This study aimed to evaluate the efficacy of antibiotic-impregnated shunt catheters (AISC) in reducing the incidence of bacterial shunt infection in patients with hydrocephalus.

METHODS: The protocol was registered on PROSPERO. A meta-analysis was conducted by searching 3 databases (PubMed, Scopus, CENTRAL) for relevant randomized controlled trials and observational studies. We included all studies published until November 2022 in any language. The primary outcome was the rate of bacterial infections, whereas the rate of shunt failure was our secondary endpoint. Odds ratios (OR) with 95% CI were calculated using a random-effects model.

RESULTS: A total of 27 articles with 27 266 shunt operations were included in this study. The results indicated that using AISC is significantly associated with reduction in infections (OR = 0.42; 95% CI: 0.33-0.54). Regarding shunt failure, there was a tendency in favor of AISC use (OR = 0.73; 95% CI: 0.51-1.06).

CONCLUSION: Our study provided evidence that AISC is significantly associated with the reduction in the rate of bacterial ventriculoperitoneal-shunt infection. In addition, there was a tendency toward AISC to decrease shunt failure compared with the standard shunt.

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Bacterial Brain Abscesses Expand Despite Effective Antibiotic Treatment: A Process Powered by Osmosis Due to Neutrophil Cell Death

Neurosurgery 94:1079–1087, 2024

A bacterial brain abscess is an emergency and should be drained of pus within 24 hours of diagnosis, as recently recommended. In this cross-sectional study, we investigated whether delaying pus drainage entails brain abscess expansion and what the underlying mechanism might be.

METHODS: Repeated brain MRI of 47 patients who did not undergo immediate pus drainage, pus osmolarity measurements, immunocytochemistry, proteomics, and 18 F-fluorodeoxyglucose positron emission tomography.

RESULTS: Time from first to last MRI before neurosurgery was 1 to 14 days. Abscesses expanded in all but 2 patients: The median average increase was 23% per day (range 0%-176%). Abscesses expanded during antibiotic therapy and even if the pus did not contain viable bacteria. In a separate patient cohort, we found that brain abscess pus tended to be hyperosmolar (median value 360 mOsm; range 266-497; n = 14; normal cerebrospinal fluid osmolarity is ∼290 mOsm). Hyperosmolarity would draw water into the abscess cavity, causing abscess expansion in a ballooning manner through increased pressure in the abscess cavity. A mechanism likely underlying pus hyperosmolarity was the recruitment of neutrophils to the abscess cavity with ensuing neutrophil cell death and decomposition of neutrophil proteins and other macromolecules to osmolytes: Pus analysis showed the presence of neutrophil proteins (protein-arginine deiminases, citrullinated histone, myeloperoxidase, elastase, cathelicidin). Previous studies have shown very high levels of osmolytes (ammonia, amino acids) in brain abscess pus. 18 F-fluorodeoxyglucose positron emission tomography showed focal neocortical hypometabolism 1 to 8 years after brain abscess, indicating long-lasting damage to brain tissue.

CONCLUSION: Brain abscesses expand despite effective antibiotic treatment. Furthermore, brain abscesses cause lasting damage to surrounding brain tissue. These findings support drainage of brain abscesses within 24 hours of diagnosis.

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Internal Ventricular Cerebrospinal Fluid Shunt for Adult Hydrocephalus: A Systematic Review and Meta-Analysis of the Infection Rate

Hydrocephalus is a common neurological condition that usually requires internal ventricular cerebrospinal fluid shunt (IVCSFS). The reported infection rate (IR) varies greatly from below 1% up to over 50%, but no meta-analysis to assess the overall IR has ever been performed.

OBJECTIVE: To determine the IVCSFS overall IR in the adult population and search for associated factors.

METHODS: Six databases were searched from January 1990 to July 2022. Only original articles reporting on adult IVCSFS IR were included. Random-effects meta-analysis with generalized linear mixed model method and logit transformation was used to assess the overall IR. RESULTS: Of 1703 identified articles, 44 were selected, reporting on 57259 patients who had IVCSFS implantation and 2546 infections. The pooled IR value and its 95% CI were 4.75%, 95% CI (3.8 to 5.92). Ninety-five percent prediction interval ranged from 1.19% to 17.1%. The patients who had IVCSFS after intracranial hemorrhage showed a higher IR (7.65%, 95% CI [5.82 to 10], P-value = .002). A meta-regression by year of publication found a decreasing IR (À0.031, 95% CI [À0.06 to 0.003], P-value = .032) over the past 32 years.

CONCLUSION: IVCSF is a procedure that every neurosurgeon should be well trained to perform. However, the complication rate remains high, with an estimated overall IR of 4.75%. The IR is especially elevated for hydrocephalic patients who require IVCSFS after intracranial hemorrhage. However, decades of surgical advances may have succeeded in reducing IR over the past 32 years.

Neurosurgery 92:894–904, 2023

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Spontaneous empyema and brain abscess in an intensive care population: clinical presentation, microbiology, and factors associated with outcome

Acta Neurochirurgica (2023) 165:651–658

Data on critically ill patients with spontaneous empyema or brain abscess are limited. The aim was to evaluate clinical presentations, factors, and microbiological findings associated with the outcome in patients treated in a Neurocritical Care Unit.

Methods In this retrospective study, we analyzed 45 out of 101 screened patients with spontaneous epidural or subdural empyema and/or brain abscess treated at a tertiary care center between January 2012 and December 2019. Patients with postoperative infections or spinal abscess were excluded. Medical records were reviewed for baseline characteristics, origin of infection, laboratory and microbiology findings, and treatment characteristics. The outcome was determined using the Glasgow outcome scale extended (GOSE).

Results Favorable outcome (GOSE 5–8) was achieved in 38 of 45 patients (84%). Four patients died (9%), three remained severely disabled (7%). Unfavorable outcome was associated with a decreased level of consciousness at admission (Glasgow coma scale < 9) (43% versus 3%; p = 0.009), need of vasopressors (71% versus 11%; p = 0.002), sepsis (43% versus 8%; p = 0.013), higher age (65.1 ± 15.7 versus 46.9 ± 17.5 years; p = 0.014), shorter time between symptoms onset and ICU admission (5 ± 2.4 days versus 11.6 ± 16.8 days; p = 0.013), and higher median C-reactive protein (CRP) serum levels (206 mg/l, range 15–259 mg/l versus 17.5 mg/l, range 3.3–72.7 mg/l; p = 0.036). With antibiotics adapted according to culture sensitivities in the first 2 weeks, neuroimaging revealed a progression of empyema or abscess in 45% of the cases.

Conclusion Favorable outcome can be achieved in a considerable proportion of an intensive care population with spontaneous empyema or brain abscess. Sepsis and more frequent need for vasopressors, associated with unfavorable outcome, indicate a fulminant course of a not only cerebral but systemic infection. Change of antibiotic therapy according to microbiological findings in the first 2 weeks should be exercised with great caution.

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Reducing the risks of proximal and distal shunt failure in adult hydrocephalus

J Neurosurg 136:877–886, 2022

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor because of high shunt failure rates. The use of neuronavigation or laparoscopy can reduce the risks of proximal or distal shunt catheter failure, respectively, but has less independent effect on overall shunt failures. No adult studies to date have combined both approaches in the setting of a shunt infection prevention protocol to reduce shunt failure. The goal of this study was to determine whether combining neuronavigation and laparoscopy with a shunt infection prevention strategy would reduce the incidence of shunt failures in adult hydrocephalic patients.

METHODS Adult patients (age ≥ 18 years) undergoing VP shunt surgery at a tertiary care institution prior to (pre–Shunt Outcomes [ShOut]) and after (post-ShOut) the start of a prospective continuous quality improvement (QI) study were compared. Pre-ShOut patients had their proximal and distal catheters placed under conventional freehand approaches. Post-ShOut patients had their shunts inserted with neuronavigational and laparoscopy assistance in placing the distal catheter in the perihepatic space (falciform technique). A shunt infection reduction protocol had been instituted 1.5 years prior to the start of the QI initiative. The primary outcome of interest was the incidence of shunt failure (including infection) confirmed by standardized criteria indicating shunt revision surgery.

RESULTS There were 244 (115 pre-ShOut and 129 post-ShOut) patients observed over 7 years. With a background of shunt infection prophylaxis, combined neuronavigation and laparoscopy was associated with a reduction in overall shunt failure rates from 37% to 14%, 45% to 22%, and 51% to 29% at 1, 2, and 3 years, respectively (HR 0.44, p < 0.001). Shunt infection rates decreased from 8% in the pre-ShOut group to 0% in the post-ShOut group. There were no proximal catheter failures in the post-ShOut group. The 2-year rates of distal catheter failure were 42% versus 20% in the pre- and post-ShOut groups, respectively (p < 0.001).

CONCLUSIONS Introducing a shunt infection prevention protocol, placing the proximal catheter under neuronavigation, and placing the peritoneal catheter in the perihepatic space by using the falciform technique led to decreased rates of infection, distal shunt failure, and overall shunt failure.

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Negligible Systemic Uptake of Suprafascial Vancomycin Powder Following Instrumented Posterior Spinal Fusion

Neurosurgery 89:967–972, 2021

Intrawound vancomycin powder is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery. However, there are concerns relating to its safety profile and toxicity. Data on systemic uptake of suprafascially administered vancomycin powder following instrumented spinal fusion is lacking.

OBJECTIVE: To study the systemic uptake and safety of suprafascially administered vancomycin powder in the early postoperative phase following open instrumented posterior spinal fusion.

METHODS: This was a substudy of an ongoing randomized clinical trial. Eligible adult patients were randomized 1:1 to either receive suprafascial vancomycin powder before wound closure or not to receive vancomycin powder. Serum vancomycin levels were assessed on postoperative days 1 and 2, serum creatinine levels were measured pre- and post-operatively. Adverse events up to 6 wk following surgery were recorded.

RESULTS:Among34 randomized patients (mean age 62 yr, range 31-84 yr; 18 [53%]women), 17 received vancomycin powder. No detectable serum vancomycin levels (>4.0mg/L)were found. Proportion of adverse events per patient in the vancomycin and control group, respectively,were 29.4% (5/17) vs 11.8% (2/17) (OR 3.12;95%CI, 0.52; 19.38; P=.398).No patient had nephrotoxicity or ototoxicity in either group. CONCLUSION: Suprafascial vancomycin powder in open instrumented spinal fusion surgery is safe and results in negligible systemic uptake. Final results of the VANCO Trial need to be awaited for conclusive data on the efficacy of vancomycin for SSI prevention and its impact on wound healing.

 

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Removal of instrumentation for postoperative spine infection: systematic review

J Neurosurg Spine 35:376–388, 2021

Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient’s spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation.

METHODS PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction.

RESULTS Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections.

CONCLUSIONS The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

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Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on the Development of Surgical Site Infection after Spinal Surgery: A Prospective Observational Study

Neurosurgery 88:E445–E451, 2021

Use of a closed-incisional negative pressure therapy (ci-NPT) dressing is an emerging strategy to reduce surgical site infections (SSIs) in spine surgery that lacks robust data.

OBJECTIVE: To determine the impact of a ci-NPT, as compared with a standard dressing, on the development of SSIs after spine surgery.

METHODS: This was a prospective observational study over a 2-yr period. Indications for surgery included degenerative disease, deformity, malignancy, and trauma. Exclusion criteria included anterior and lateral approaches to the spine, intraoperative durotomy, or use of minimally invasive techniques. SSIs up to 60d following surgery were recorded.

RESULTS: A total of 274 patients were included. SSI rate was significantly lower with ci-NPT dressing (n = 118) as compared with the standard dressing (n = 156) (3.4 vs 10.9%, P = .02). There was no statistical difference in infection rate for decompression alone procedures (4.2 vs 9.1%, P = .63), but there was a statistically significant reduction with the use of a negative-pressure dressing in cases that required instrumentation (3.2 vs 11.4%, P = .03). Patients at higher risk (instrumentation, deformity, and malignancy) had less SSIs with the use of ci-NPT, although this did not reach statistical significance. There were no complications in either group.

CONCLUSION: SSI rates were significantly reduced with a ci-NPT dressing vs a standard dressing in patients who underwent spinal surgery. The higher cost of a ci-NPT dressing might be justified with instrumented cases, as well as with certain high-risk patient populations undergoing spine surgery, given the serious consequences of an infection.

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Intrawound vancomycin application after spinal surgery: a propensity score–matched cohort analysis

J Neurosurg Spine 34:788–798, 2021

Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates.

METHODS The authors performed a retrospective, vancomycin exposure–matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort.

RESULTS A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance.

CONCLUSIONS The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram negative bacteria and increase rates of wound disruption.

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Occult infection in pseudarthrosis revision after spinal fusion

The Spine Journal 21 (2021) 370−376

Pseudarthrosis after attempted spinal fusion is yet not sufficiently understood and presents a surgical challenge. Occult infections are sometimes observed in patients with pseudarthrosis and no inflammatory signs of infection. The prevalence of such occult infection and its association with patient demographics and inflammatory markers are largely unknown.

PURPOSE: To determine the prevalence of unexpected low-grade infection in spinal pseudarthrosis revision surgery, and to evaluate whether such infection is associated with patient demographics and inflammatory markers.

STUDY DESIGN: Retrospective observational study.

PATIENT SAMPLE: One-hundred-and-twenty-eight patients who underwent thoracolumbar revision surgery due to presumed aseptic pseudarthrosis after spinal instrumentation.

OUTCOME MEASURES: Culture-positive infections or noninfectious pseudarthrosis. METHODS: Samples were routinely taken for microbiological examination from all adults (n=152) who underwent revision surgery for presumed aseptic thoracolumbar pseudarthrosis between 2014 and 2019. A full intraoperative microbiological workup (at least three intraoperative tissue samples) was done for 128 (84%) patients, and these patients were included in further analyses. Patient characteristics, medical history, inflammatory markers, and perioperative data were compared between those with and without microbiologically-confirmed infection based on samples obtained during pseudarthrosis revision.

RESULTS: The microbiological workup confirmed infection in 13 of 128 cases (10.2%). The predominant pathogen was Cutibacterium acnes (46.2%), followed by coagulase-negative staphylococci (38.5%). The presence of infection was associated with the body mass index (30.9§4.7 kg/m2 [infected] vs. 28.2§5.6 kg/m2 [controls], p=.049), surgery in the thoracolumbar region (46% vs. 18%, p=.019), and a slightly higher serum C-reactive protein level on admission (9.4§8.0 mg/L vs. 5.7§7.1 mg/L, p=.031). Occult infection was not associated with age, sex, prior lumbar surgeries, number of fused lumbar levels, American Society of Anesthesiologist score, Charlson Comorbidity Index, presence of diabetes mellitus, and smoking status.

CONCLUSIONS: Occult infections were found in 10% of patients undergoing pseudarthrosis revision after spinal fusion, even without preoperative clinical suspicion. Occult infection was associated with higher body mass index, fusions including the thoracolumbar junction, and slightly higher C-reactive protein levels. Intraoperative microbiological samples should be routinely obtained to exclude or identify occult infection in all revision surgeries for symptomatic pseudarthrosis of the spine, as this information can be used to guide postoperative antibiotic treatment.

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The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement

Neurosurgery 88(2)2021: 301–305

Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts.

OBJECTIVE: To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement.

METHODS: This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephaluswere included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection.

RESULTS: A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P=.038). Of those receiving intraventricular antibiotics, only 2 (0.38%)went on to undergo re-intervention due to infection.

CONCLUSION: These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.

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Low-Grade Infection and Implant Failure Following Spinal Instrumentation

Neurosurgery 87:964–970, 2020

Spinal instrumentation can be associated with complications, including implant loosening. Hitherto, implant loosening has mainly been attributed to mechanical overload.

OBJECTIVE: To examine the role of low-grade infections as the cause of implant failure in suspected aseptic implant loosening following spinal instrumentation.

METHODS: A prospective single center observational study was performed. All patients who had revision surgery following spinal instrumentation between August 2015 and February 2018 were screened. Patients with revision surgery due to screw loosening on the computed tomograhy scan constituted the study group. Patients in which the screws where not loosened but removalwas performed for other reasons formed the comparison group. Intraoperative swabswere taken and sonicationwas performedwith the explanted material. Results of microbiological cultivation were analyzed.

RESULTS: A total of 59 patients were included in the study group and 34 in the comparison group. In the study group in 42.4% of the cultures a bacterium was detected, while in the comparison group only in 17.6%. 84%, and 83.3% of these germs were detected by sonication in the study and comparison group, respectively. The rate of positive cultures was significantly higher in the study group compared to the comparison group (P= .001). The most frequent bacterium cultivated in both groups was Propionibacterium acnes, followed by Staphylococcus species.

CONCLUSION: For patients with screw loosening a high level of suspicion for a low-grade infection should be raised. Cultures should be performed from the sonication fluid of the explanted devices in all patients with symptomatic screw loosening.

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Double-blind randomized clinical trial of vancomycin in spinal arthrodesis: no effects on surgical site infection

J Neurosurg Spine 32:473–480, 2020

Surgical site infection (SSI) results in high morbidity and mortality in patients undergoing spinal fusion. Using intravenous antibiotics in anesthesia induction reduces the rate of postoperative infection, but it is not common practice to use them topically, despite recent reports that this procedure helps reduce infection. The objective of this study was to determine whether the topical use of vancomycin reduces the rate of postoperative SSI in patients undergoing thoracolumbar fusion.

METHODS A randomized, double-blind clinical trial in a single hospital was performed comparing vancomycin and placebo in thoracolumbar fusion patients.

RESULTS A total of 96 patients were randomized to placebo or vancomycin treatment. The mean patient age was 43 ± 14.88 years, 74% were male, and the most common etiology was fall from height (46.9%). The overall rate of postoperative SSI was 8.3%, and no difference was found between the groups: postoperative infection rates in the vancomycin and placebo groups were 8.2% and 8.5% (relative risk [RR] of SSI not using vancomycin 1.04, 95% confidence interval [CI] 0.28–3.93, p = 0.951), respectively. Patients with diabetes mellitus had higher SSI rates (RR 8.98, 95% CI 1.81–44.61, p = 0.007).

CONCLUSIONS This is the first double-blind randomized clinical trial to evaluate the effects of topical vancomycin on postoperative infection rates in thoracolumbar fusion patients, and the results did not differ significantly from placebo. Clinical trial registration no.: RBR-57wppt (ReBEC; http://www.ensaiosclinicos.gov.br/)

 

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Greening the Operating Room: Results of a Scalable Initiative to Reduce Waste and Recover Supply Costs

Neurosurgery 85:432–437, 2019

Operating rooms generate 42% of a hospital’s revenue and 30% of hospital waste. Supply costs are 56% of a total operating room (OR) budget. US academic medical centers use 2 million pounds ($15 million) of recoverable medical supplies annually. Forming a multidisciplinary leadership team, we analyzed sources of waste focusing on our Department of Neurosurgery. We developed an 8-wk pilot project to recycle “blue wrap,” the number 5 plastic polypropylene material that is ubiquitously used in ORs across the country to wrap instrument pans and implant trays for sterilization. Blue wrap can be baled and sold to recyclers where the material is pelletized and transformed into plastic products.

During the 39 d of the pilot, we collected 1247 pounds of blue wrap (32 lbs collected daily). The cost of the pilot was $14987 that includes a new baler ($11200) and 5 transport carts ($3697). The revenue received from baled blue wrap was 8 cents per pound. Cost avoidance yielded $31680.00 in savings. Implementation of this pilot across our main hospital would yield $5000 in revenue annually and $174.240 in cost avoidance.

This project can be replicated at other centers and not only reduces the environmental footprint, but also helps generate additional revenue by recycling a necessary packing material that would otherwise require payment for disposal.

 

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Evaluation of neurosurgical implant infection rates and associated pathogens: evidence from 1118 postoperative infections

Neurosurg Focus 47 (2):E6, 2019

Various implanted materials are used in neurosurgery; however, there remains a lack of pooled data on infection rates (IRs) and infective bacteria over past decades. The goal of this study was to investigate implant infections in neurosurgical procedures in a longitudinal retrospective study and to evaluate the IRs of neurosurgically implanted materials and the distribution of pathogenic microorganisms.

METHODS A systematic literature search was conducted using PubMed and Web of Science databases for the time period between 1968 and 2018. Neurosurgical implant infections were studied in 5 subgroups, including operations or diseases, implanted materials, bacteria, distribution by country, and time periods, which were obtained from the literature and statistically analyzed. In this meta-analysis, statistical heterogeneity across studies was tested by using p values and I2 values between studies of associated pathogens. Egger’s test was used for assessing symmetries of funnel plots with Stata 11.0 software. Methodological quality was assessed to judge the risk of bias according to the Cochrane Handbook.

RESULTS A total of 22,971 patients from 227 articles satisfied the study’s eligibility criteria. Of these, 1118 cases of infection were reported, and the overall IR was 4.87%. In this study, the neurosurgical procedures or disorders with the top 3 IRs included craniotomy (IR 6.58%), cranioplasty (IR 5.89%), and motor movement disorders (IR 5.43%). Among 13 implanted materials, the implants with the top 3 IRs included polypropylene-polyester, titanium, and polyetheretherketone (PEEK), which were 8.11%, 8.15%, and 7.31%, respectively. Furthermore, the main causative pathogen was Staphylococcus aureus and the countries with the top 3 IRs were Denmark (IR 11.90%), Korea (IR 10.98%), and Mexico (IR 9.26%). Except for the low IR from 1998 to 2007, the overall implant IR after neurosurgical procedures was on the rise.

CONCLUSIONS In this study, the main pathogen in neurosurgery was S. aureus, which can provide a certain reference for the clinic. In addition, the IRs of polypropylene-polyester, titanium, and PEEK were higher than other materials, which means that more attention should be paid to them. In short, the total IR was high in neurosurgical implants and should be taken seriously.

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