Deep brain stimulation hardware–related infections: 10-year experience at a single institution

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  • 1 Departments of Neurosurgery and
  • 2 Internal Medicine,
  • 3 University of Iowa Carver College of Medicine;
  • 4 Program of Hospital Epidemiology, University of Iowa Hospitals and Clinics; and
  • 5 Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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OBJECTIVE

Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP).

METHODS

The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network’s definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher’s exact test, or logistic regression, as appropriate for the variables examined.

RESULTS

Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10–1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10–1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations.

CONCLUSIONS

While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.

ABBREVIATIONS ASA = American Society of Anesthesiologists; BMI = body mass index; DBS = deep brain stimulator; GPI = globus pallidus internus; IPG = implantable pulse generator; IV = intravenous; MSSA = methicillin-susceptible Staphylococcus aureus; NHSN = National Healthcare Safety Network; OCD = obsessive-compulsive disorder; SSI = surgical site infection; STN = subthalamic nucleus; VC = ventral capsule; VIM = ventralis intermedius; VP = vancomycin powder; VS = ventral striatum.

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Contributor Notes

Correspondence Jeremy D. W. Greenlee: University of Iowa Hospitals and Clinics, Iowa City, IA. jeremy-greenlee@uiowa.edu.

INCLUDE WHEN CITING Published online March 9, 2018; DOI: 10.3171/2017.9.JNS1780.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Abdullah KG, Attiah MA, Olsen AS, Richardson A, Lucas TH: Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin. J Neurosurg 123:16001604, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Abode-Iyamah KO, Chiang HY, Winslow N, Park B, Zanaty M, Dlouhy BJ, : Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty. J Neurosurg [epub ahead of print May 12, 2017; DOI: 10.3171/2016.12.JNS161967]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bakhsheshian J, Dahdaleh NS, Lam SK, Savage JW, Smith ZA: The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg 83:816823, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Bekhtereva NP, Grachev KV, Orlova AN: Iatsuksl. [Utilization of multiple electrodes implanted in the subcortical structure of the human brain for the treatment of hyperkinesis.] Zh Nevropatol Psikhiatr Im S S Korsakova 63:38, 1963 (Russian)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Benabid AL, Pollak P, Louveau A, Henry S, de Rougemont J: Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease. Appl Neurophysiol 50:344346, 1987

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bhatia R, Dalton A, Richards M, Hopkins C, Aziz T, Nandi D: The incidence of deep brain stimulator hardware infection: the effect of change in antibiotic prophylaxis regimen and review of the literature. Br J Neurosurg 25:625631, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Bhatia S, Zhang K, Oh M, Angle C, Whiting D: Infections and hardware salvage after deep brain stimulation surgery: a single-center study and review of the literature. Stereotact Funct Neurosurg 88:147155, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Blomstedt P, Bjartmarz H: Intracerebral infections as a complication of deep brain stimulation. Stereotact Funct Neurosurg 90:9296, 2012

  • 9

    Blomstedt P, Hariz MI: Hardware-related complications of deep brain stimulation: a ten year experience. Acta Neurochir (Wien) 147:10611064, 2005

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Boviatsis EJ, Stavrinou LC, Themistocleous M, Kouyialis AT, Sakas DE: Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature. Acta Neurochir (Wien) 152:20532062, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Brandmeir N, Nehrbass E, McInerney J: An analysis of scalp thickness and other novel risk factors for deep brain stimulator infections. Cureus 8:e792, 2016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, : Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 14:73156, 2013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    Centers for Disease Control and Prevention: The National Healthcare Safety Network (NHSN) Manual: Procedure-associated Module: Division Surgical Site Infection (SSI). (http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf) [Accessed November 17, 2017]

    • Search Google Scholar
    • Export Citation
  • 14

    Chiang HY, Herwaldt LA, Blevins AE, Cho E, Schweizer ML: Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. Spine J 14:397407, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Chopra A, Klassen BT, Stead M: Current clinical application of deep-brain stimulation for essential tremor. Neuropsychiatr Dis Treat 9:18591865, 2013

  • 16

    Constantoyannis C, Berk C, Honey CR, Mendez I, Brownstone RM: Reducing hardware-related complications of deep brain stimulation. Can J Neurol Sci 32:194200, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Dao H Jr, Kazin RA: Gender differences in skin: a review of the literature. Gend Med 4:308328, 2007

  • 18

    Deuschl G, Schade-Brittinger C, Krack P, Volkmann J, Schäfer H, Bötzel K, : A randomized trial of deep-brain stimulation for Parkinson’s disease. N Engl J Med 355:896908, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Dlouhy BJ, Reddy A, Dahdaleh NS, Greenlee JD: Antibiotic impregnated catheter coverage of deep brain stimulation leads facilitates lead preservation after hardware infection. J Clin Neurosci 19:13691375, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Doshi PK: Long-term surgical and hardware-related complications of deep brain stimulation. Stereotact Funct Neurosurg 89:8995, 2011

  • 21

    Fenoy AJ, Simpson RK Jr: Risks of common complications in deep brain stimulation surgery: management and avoidance. J Neurosurg 120:132139, 2014

  • 22

    Ghobrial GM, Cadotte DW, Williams K Jr, Fehlings MG, Harrop JS: Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus 39(4):E11, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Gionfriddo MR, Greenberg AJ, Wahegaonkar AL, Lee KH: Pathways of translation: deep brain stimulation. Clin Transl Sci 6:497501, 2013

  • 24

    Godil SS, Parker SL, O’Neill KR, Devin CJ, McGirt MJ: Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine 19:331335, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Gorgulho A, Juillard C, Uslan DZ, Tajik K, Aurasteh P, Behnke E, : Infection following deep brain stimulator implantation performed in the conventional versus magnetic resonance imaging-equipped operating room. J Neurosurg 110:239246, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Greenberg BD, Askland KD, Carpenter LL: The evolution of deep brain stimulation for neuropsychiatric disorders. Front Biosci 13:46384648, 2008

  • 27

    Haleem A, Chiang HY, Vodela R, Behan A, Pottinger JM, Smucker J, : Risk factors for surgical site infections following adult spine operations. Infect Control Hosp Epidemiol 37:14581467, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Halpern CH, Mitchell GW, Paul A, Kramer DR, McGill KR, Buonacuore D, : Self-administered preoperative antiseptic wash to prevent postoperative infection after deep brain stimulation. Am J Infect Control 40:431433, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13:606608, 1992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Johnson MD, Miocinovic S, McIntyre CC, Vitek JL: Mechanisms and targets of deep brain stimulation in movement disorders. Neurotherapeutics 5:294308, 2008

  • 31

    Khan NR, Thompson CJ, DeCuypere M, Angotti JM, Kalobwe E, Muhlbauer MS, : A meta-analysis of spinal surgical site infection and vancomycin powder. J Neurosurg Spine 21:974983, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Krack P, Batir A, Van Blercom N, Chabardes S, Fraix V, Ardouin C, : Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease. N Engl J Med 349:19251934, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Kuhn J, Lenartz D, Huff W, Lee S, Koulousakis A, Klosterkoetter J, : Remission of alcohol dependency following deep brain stimulation of the nucleus accumbens: valuable therapeutic implications? J Neurol Neurosurg Psychiatry 78:11521153, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Levy D, Shabat-Simon M, Shalev U, Barnea-Ygael N, Cooper A, Zangen A: Repeated electrical stimulation of reward-related brain regions affects cocaine but not “natural” reinforcement. J Neurosci 27:1417914189, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Lyons MK: Deep brain stimulation: current and future clinical applications. Mayo Clin Proc 86:662672, 2011

  • 36

    Mayberg HS, Lozano AM, Voon V, McNeely HE, Seminowicz D, Hamani C, : Deep brain stimulation for treatment-resistant depression. Neuron 45:651660, 2005

  • 37

    Miller JP, Acar F, Burchiel KJ: Significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin/polymyxin application. J Neurosurg 110:247250, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Müller UJ, Sturm V, Voges J, Heinze HJ, Galazky I, Heldmann M, : Successful treatment of chronic resistant alcoholism by deep brain stimulation of nucleus accumbens: first experience with three cases. Pharmacopsychiatry 42:288291, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Nuttin B, Cosyns P, Demeulemeester H, Gybels J, Meyerson B: Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder. Lancet 354:1526, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    O’Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, : Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J 11:641646, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Pepper J, Zrinzo L, Mirza B, Foltynie T, Limousin P, Hariz M: The risk of hardware infection in deep brain stimulation surgery is greater at impulse generator replacement than at the primary procedure. Stereotact Funct Neurosurg 91:5665, 2013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Piacentino M, Pilleri M, Bartolomei L: Hardware-related infections after deep brain stimulation surgery: review of incidence, severity and management in 212 single-center procedures in the first year after implantation. Acta Neurochir (Wien) 153:23372341, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Rasouli JJ, Kopell BH: The adjunctive use of vancomycin powder appears safe and may reduce the incidence of surgical-site infections after deep brain stimulation surgery. World Neurosurg 95:913, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Rehncrona S, Johnels B, Widner H, Törnqvist AL, Hariz M, Sydow O: Long-term efficacy of thalamic deep brain stimulation for tremor: double-blind assessments. Mov Disord 18:163170, 2003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Rodriguez-Oroz MC, Obeso JA, Lang AE, Houeto JL, Pollak P, Rehncrona S, : Bilateral deep brain stimulation in Parkinson’s disease: a multicentre study with 4 years follow-up. Brain 128:22402249, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Sillay KA, Larson PS, Starr PA: Deep brain stimulator hardware-related infections: incidence and management in a large series. Neurosurgery 62:360367, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 47

    Strom RG, Pacione D, Kalhorn SP, Frempong-Boadu AK: Decreased risk of wound infection after posterior cervical fusion with routine local application of vancomycin powder. Spine (Phila Pa 1976) 38:991994, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Sun B, Liu W: Stereotactic surgery for eating disorders. Surg Neurol Int 4 (Suppl 3):S164S169, 2013

  • 49

    Sweet FA, Roh M, Sliva C: Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: efficacy, drug levels, and patient outcomes. Spine (Phila Pa 1976) 36:20842088, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Tolleson C, Stroh J, Ehrenfeld J, Neimat J, Konrad P, Phibbs F: The factors involved in deep brain stimulation infection: a large case series. Stereotact Funct Neurosurg 92:227233, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Vandewalle V, van der Linden C, Groenewegen HJ, Caemaert J: Stereotactic treatment of Gilles de la Tourette syndrome by high frequency stimulation of thalamus. Lancet 353:724, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Wichmann T, DeLong MR: Deep brain stimulation for movement disorders of basal ganglia origin: restoring function or functionality? Neurotherapeutics 13:264283, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Xiong L, Pan Q, Jin G, Xu Y, Hirche C: 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 Res 100:785789, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Ying S, Zeng DN, Chi L, Tan Y, Galzote C, Cardona C, : The influence of age and gender on skin-associated microbial communities in urban and rural human populations. PLoS One 10:e0141842, 2015

    • Crossref
    • Search Google Scholar
    • Export Citation

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