Clinical significance of positive cranial bone flap cultures and associated risk of surgical site infection after craniotomies or craniectomies

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Object

The risk of surgical site infection (SSI) after craniotomies or craniectomies in patients in whom contaminated bone flaps have been reimplanted has not been determined. The objectives of this study were to identify the prevalence of bone flaps with positive cultures—especially those contaminated with Propionibacterium acnes—to assess the risk of SSI after reimplanting (either during the initial operation or subsequently) bone flaps with positive cultures, and to identify risk factors for SSI following the initial craniotomies or craniectomies.

Methods

The authors conducted a retrospective review of cases in which patients underwent craniotomy/craniectomy procedures between January and October 2007 in the neurosurgery department at the University of Iowa Hospitals and Clinics. They also reviewed processes and procedures and did pulsed field gel electrophoresis of P. acnes isolates to look for a common source of contamination. They then conducted a prospective cohort study that included all patients who underwent craniotomy/craniectomy procedures between November 2007 and November 2008 and met the study criteria. For the cohort study, the authors obtained cultures from each patient's bone flap during the craniotomy/craniectomy procedures. Data about potential risk factors were collected by circulating nurses during the procedures or by a research assistant who reviewed medical records after the procedures. An infection preventionist independently identified SSIs through routine surveillance using the Centers for Disease Control and Prevention's definitions. Univariate and bivariate analyses were performed to determine the association between SSI and potential risk factors.

Results

The retrospective review did not identify specific breaks in aseptic technique or a common source of P. acnes. Three hundred seventy-three patients underwent 393 craniotomy/craniectomy procedures during the cohort study period, of which 377 procedures met the study criteria. Fifty percent of the bone flaps were contaminated by microorganisms, primarily skin flora such as P. acnes, coagulase-negative staphylococci, and Staphylococcus aureus. Reimplanting bone flaps that had positive culture results did not increase the risk of infection after the initial craniotomy/craniectomy procedures and the subsequent cranioplasty procedures (p = 0.80). Allowing the skin antiseptic to dry before the procedures (p = 0.04, OR 0.26) was associated with lower risk of SSIs. Female sex (p = 0.02, OR = 3.49) was associated with an increased risk of SSIs; Gliadel wafer implants (p = 0.001, OR = 8.38) were associated with an increased risk of SSIs after procedures to treat tumors.

Conclusions

Operative factors such as the way the skin is prepared before the incision rather than the skin flora contaminants on the bone flaps may play an important role in the pathogenesis of SSIs after craniotomy/craniectomy. Gliadel wafers significantly increased the risk of SSI after procedures to treat tumors.

Abbreviations used in this paper: CHG = chlorhexidine gluconate; CoNS = coagulase-negative staphylococci; SSI = surgical site infection; UIHC = University of Iowa Hospitals and Clinics.

Article Information

Address correspondence to: Jeremy D. W. Greenlee, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. email: jeremy-greenlee@uiowa.edu.

Please include this information when citing this paper: published online March 4, 2011; DOI: 10.3171/2011.1.JNS10782.

© AANS, except where prohibited by US copyright law.

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    Flow chart describing information obtained in the study population. *The risk of SSI after the initial craniotomies/craniectomies when bone flaps were reimplanted immediately (16 [5.4%] of 297) was not significantly different from the risk of SSI when bone flaps were banked (4 [5.0%] of 80) (p = 1.00, Fisher exact test). †Twenty SSIs occurred in 20 patients after the initial craniotomy/craniectomy procedures. ‡Follow-up information through 11/30/2009 is provided for the 80 procedures (79 patients) for which bone flaps were banked (beneath the broken line). However, risk factors for SSIs were assessed only for the initial craniotomy/craniectomy procedures (above the broken line), not for delayed cranioplasty procedures. §These 2 SSIs were not included in the study of risk factors for SSIs. One of the 2 patients also acquired an SSI after the initial craniotomy/craniectomy; this initial SSI was included in the risk factor study.

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