In this historical vignette, the authors discuss the prevention of surgical site infections (SSIs) after brain surgery from the prehistoric period to the present. Although the mechanism for infection was not fully understood until the 19th century, records demonstrate that as early as 10,000 bc, practitioners used gold, a biocidal material, for cranioplasties and attempted to approximate wounds by tying a patient’s hair across the incision. Written records from the Egyptian and Babylonian period depict the process of soaking head dressings in alcohol, an antibacterial agent. In the Greek and Early Byzantine period, Hippocrates argued against the formation of pus in wounds and continued to champion the use of wine in wound management. In the 16th century, intracranial silver drains were first utilized in an effort to prevent postoperative infections. The turning point of SSI prevention was in 1867, when Joseph Lister illustrated the connection between Louis Pasteur’s discovery of the fermentation process and the suppuration of wounds. Today, there are ongoing investigations and debates about the optimal techniques to prevent SSI after brain surgery. Although tremendous progress in the field of SSI prevention since the prehistoric period has been made, SSI continues to affect morbidity and mortality after brain surgery.
Elizabeth Carroll and Ariane Lewis
Ariane Lewis, Aaron Rothstein and Donato Pacione
The objective of this study was to determine the effects of a quality improvement initiative in which daily antibiotics and daily sampling of cerebrospinal fluid (CSF) were discontinued for patients with lumbar drains.
The frequency of surgical site infections (SSIs), antibiotic-related complications (development of Clostridium difficile infection [CDI] and growth of resistant bacteria), and cost for patients with lumbar drains were compared during 3 periods: 1) prolonged prophylactic systemic antibiotics (PPSA) until the time of drain removal and daily CSF sampling (September 2013–2014), 2) PPSA and CSF sampling once after placement then as needed (January 2015–2016), and 3) antibiotics only during placement of the lumbar drain and CSF sampling once after placement then as needed (April 2016–2017).
Thirty-nine patients were identified in period 1, 53 patients in period 2, and 39 patients in period 3. There was no change in the frequency of SSI after discontinuation of routine CSF testing or PPSA (0% in period 1, 2% in period 2, and 0% in period 3). In periods 1 and 2, 3 patients developed infections due to resistant organisms and 2 patients had CDI. In period 3, 1 patient had an infection due to a resistant organism. The median cost of CSF tests per patient was $100.68 (interquartile range [IQR] $100.68–$134.24) for patients in period 1 and $33.56 (IQR $33.56–$33.56) in periods 2 and 3 (p < 0.001). The median cost of antibiotics per patient was $26.32 (IQR $26.32–$30.65) in periods 1 and 2 and $3.29 ($3.29–$3.29) in period 3 (p < 0.001). The cost associated with growth of resistant bacteria and CDI was $91,291 in periods 1 and 2 and $25,573 in period 3.
After discontinuing daily antibiotics and daily CSF sampling for patients with lumbar drains, the frequency of SSI was unchanged and the frequency of antibiotic-related complications decreased.
Ariane Lewis, Amol Raheja and Ian E. McCutcheon
Ariane Lewis, Rajeev Sen, Travis C. Hill, Herbert James, Jessica Lin, Harpaul Bhamra, Nina Martirosyan and Donato Pacione
The authors sought to determine the effects of eliminating the use of prolonged prophylactic systemic antibiotics (PPSAs) in patients with subdural and subgaleal drains.
Using a retrospective database, the authors collected data for patients over the age of 17 years who had undergone cranial surgery at their institution between December 2013 and July 2014 (PPSAs period) or between December 2014 and July 2015 (non-PPSAs period) and had subdural or subgaleal drains left in place postoperatively.
One hundred five patients in the PPSAs period and 80 in the non-PPSAs period were identified. The discontinuation of PPSAs did not result in an increase in the frequency of surgical site infection (SSI). The frequency of Clostridium difficile (CDI) and the growth of resistant bacteria were reduced in the non-PPSAs period in comparison with the PPSAs period. In the 8 months after the drain prophylaxis protocol was changed, $93,194.63 were saved in the costs of antibiotics and complications related to antibiotics.
After discontinuing PPSAs for patients with subdural or subgaleal drains at their institution, the authors did not observe an increase in the frequency of SSI. They did, however, note a decrease in the frequency of CDI and the growth of resistant organisms. It appears that not only can patients in this population do without PPSAs, but also that complications are avoided when antibiotic use is limited to 24 hours after surgery.