Craniectomy is often performed to decrease intracranial pressure following trauma and vascular injuries. The subsequent cranioplasty procedures may be complicated by surgical site infections (SSIs) due to prior trauma, foreign implants, and multiple surgeries through a common incision. Several studies have found that intrawound vancomycin powder (VP) is associated with decreased risk of SSIs after spine operations. However, no previously published study has evaluated the effectiveness of VP in cranioplasty procedures. The purpose of this study was to determine whether intrawound VP is associated with decreased risk of SSIs, to evaluate VP’s safety, and to identify risk factors for SSIs after cranioplasty among patients undergoing first-time cranioplasty.
The authors conducted a retrospective cohort study of adult patients undergoing first-time cranioplasty for indications other than infections from January 1, 2008, to July 31, 2014, at an academic health center. Data on demographics, possible risk factors for SSIs, and treatment with VP were collected from the patients’ electronic health records.
During the study period, 258 patients underwent first-time cranioplasties, and 15 (5.8%) of these patients acquired SSIs. Ninety-two patients (35.7%) received intrawound VP (VP group) and 166 (64.3%) did not (no-VP group). Patients in the VP group and the no-VP group were similar with respect to age, sex, smoking history, body mass index, and SSI rates (VP group 6.5%, no-VP group 5.4%, p = 0.72). Patients in the VP group were less likely than those in the no-VP group to have undergone craniectomy for tumors and were more likely to have an American Society of Anesthesiologists physical status score > 2. Intrawound VP was not associated with other postoperative complications. Risk factors for SSI from the bivariable analyses were diabetes (odds ratio [OR] 3.65, 95% CI 1.07–12.44), multiple craniotomy procedures before the cranioplasty (OR 4.39, 95% CI 1.47–13.18), prior same-side craniotomy (OR 4.73, 95% CI 1.57–14.24), and prosthetic implants (OR 4.51, 95% CI 1.40–14.59). The multivariable analysis identified prior same-side craniotomy (OR 3.37, 95% CI 1.06–10.79) and prosthetic implants (OR 3.93, 95% CI 1.15–13.40) as significant risk factors for SSIs. After adjusting for potential confounders, patients with SSIs were more likely than those without SSIs to be readmitted (OR 7.28, 95% CI 2.07–25.60).
In this study, intrawound VP was not associated with a decreased risk of SSIs or with an increased risk of complications. Prior same-side craniotomy and prosthetic implants were risk factors for SSI after first-time cranioplasty.
ABBREVIATIONSASA = American Society of Anesthesiologists; BMI = body mass index; IV = intravenous; NHSN = National Healthcare Safety Network; OR = odds ratio; SSI = surgical site infection; VP = vancomycin powder.
AbdullahKG, AttiahMA, OlsenAS, RichardsonA, LucasTH: Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin. 123:1600–1604, 20152609083510.3171/2014.12.JNS142092)| false
ArchavlisE, Carvi Y NievasM: The impact of timing of cranioplasty in patients with large cranial defects after decompressive hemicraniectomy. 154:1055–1062, 20122252757410.1007/s00701-012-1333-1)| false
ChiangHY, HerwaldtLA, BlevinsAE, ChoE, SchweizerML: Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. 14:397–407, 201410.1016/j.spinee.2013.10.01224373682)| false
ChiangHY, KamathAS, PottingerJM, GreenleeJD, HowardMAIII, CavanaughJE, : Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy. 120:509–521, 201410.3171/2013.9.JNS1384324205908)| false
ChiangHYSteelmanVMPottingerJMSchlueterAJDiekemaDJGreenleeJD: Clinical significance of positive cranial bone flap cultures and associated risk of surgical site infection after craniotomies or craniectomies. J Neurosurg114:1746–17542011
ChiangHY, SteelmanVM, PottingerJM, SchlueterAJ, DiekemaDJ, GreenleeJD, : Clinical significance of positive cranial bone flap cultures and associated risk of surgical site infection after craniotomies or craniectomies. 114:1746–1754, 201110.3171/2011.1.JNS1078221375380)| false
ChibbaroSDi RoccoFMironeGFriciaMMakieseODi EmidioP: Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients. World Neurosurg75:558–5622011
ChibbaroS, Di RoccoF, MironeG, FriciaM, MakieseO, Di EmidioP, : Decompressive craniectomy and early cranioplasty for the management of severe head injury: a prospective multicenter study on 147 patients. 75:558–562, 20112160051210.1016/j.wneu.2010.10.020)| false
FurnaryAPZerrKJGrunkemeierGLStarrA: Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg67:352–3621999
GhobrialGM, CadotteDW, WilliamsKJr, FehlingsMG, HarropJS: Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. 39(4):E11, 20152642433510.3171/2015.7.FOCUS15258)| false
HoranTCGaynesRPMartoneWJJarvisWREmoriTG: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol13:606–6081992
HoranTC, GaynesRP, MartoneWJ, JarvisWR, EmoriTG: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. 13:606–608, 199210.1017/S01959417000152411334988)| false
HwangJS, KimSJ, BamneAB, NaYG, KimTK: Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes?473:1726–1731, 20152540440210.1007/s11999-014-4056-1)| false
InamasuJKuramaeTNakatsukasaM: 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 Trauma68:183–1872010
InamasuJ, KuramaeT, NakatsukasaM: 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. 68:183–187, 20102006577310.1097/TA.0b013e3181c45384)| false
KangDG, HolekampTF, WagnerSC, LehmanRAJr: Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. 15:762–770, 201510.1016/j.spinee.2015.01.03025637469)| false
LazarHLKetchedjianAHaimeMKarlsonKCabralH: Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. J Thorac Cardiovasc Surg148:1035–10402014
LazarHL, KetchedjianA, HaimeM, KarlsonK, CabralH: Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. 148:1035–1040, 201410.1016/j.jtcvs.2014.06.04525129595)| false
LeeL, KerJ, QuahBL, ChouN, ChoyD, YeoTT: A retrospective analysis and review of an institution’s experience with the complications of cranioplasty. 27:629–635, 201310.3109/02688697.2013.81531323879443)| false
O’NeillKRSmithJGAbtahiAMArcherKRSpenglerDMMcGirtMJ: Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J11:641–6462011
ParedesICastaño-LeónAMMunarrizPMMartínez-PerezRCepedaSSanzR: Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement. Neurocirugia (Astur)26:115–1252015
RossetoRS, GiannettiAV, de Souza FilhoLD, FaleiroRM: Risk factors for graft infection after cranioplasty in patients with large hemicranial bony defects. 84:431–437, 201510.1016/j.wneu.2015.03.04525841754)| false
SchweizerMPerencevichEMcDanelJCarsonJFormanekMHafnerJ: Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ346:f27432013
SchweizerM, PerencevichE, McDanelJ, CarsonJ, FormanekM, HafnerJ, : Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. 346:f2743, 201310.1136/bmj.f274323766464)| false
SchweizerML, ChiangHY, SeptimusE, MoodyJ, BraunB, HafnerJ, : Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. 313:2162–2171, 20152603495610.1001/jama.2015.5387)| false
SongJ, LiuM, MoX, DuH, HuangH, XuGZ: Beneficial impact of early cranioplasty in patients with decompressive craniectomy: evidence from transcranial Doppler ultrasonography. 156:193–198, 20142415018810.1007/s00701-013-1908-5)| false
SweetFA, RohM, SlivaC: Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. 36:2084–2088, 20112130443810.1097/BRS.0b013e3181ff2cb1)| false
ThavarajahD, De LacyP, HussienA, SugarA: The minimum time for cranioplasty insertion from craniectomy is six months to reduce risk of infection—a case series of 82 patients. 26:78–80, 201210.3109/02688697.2011.60385021973063)| false
TubakiVRRajasekaranSShettyAP: Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976)38:2149–21552013
TubakiVR, RajasekaranS, ShettyAP: Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. 38:2149–2155, 201310.1097/BRS.000000000000001524048091)| false
XiongLPanQJinGXuYHircheC: Topical intrawound application of vancomycin powder in addition to intravenous administration of antibiotics: a meta-analysis on the deep infection after spinal surgeries. Orthop Traumatol Surg Res100:785–7892014
XiongL, PanQ, JinG, XuY, HircheC: Topical intrawound application of vancomycin powder in addition to intravenous administration of antibiotics: a meta-analysis on the deep infection after spinal surgeries. 100:785–789, 20142528155010.1016/j.otsr.2014.05.022)| false
YadlaS, CampbellPG, ChitaleR, MaltenfortMG, JabbourP, SharanAD: Effect of early surgery, material, and method of flap preservation on cranioplasty infections: a systematic review. 68:1124–1130, 20112124283010.1227/NEU.0b013e31820a5470)| false