Risk factors for surgical site infections and assessment of vancomycin powder as a preventive measure in patients undergoing first-time cranioplasty

Abstract

OBJECTIVE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.

Risk factors for surgical site infection after craniotomy: a prospective cohort study

“…If the follow up was for 30 days the SSI-CRAN rate would be 58 episodes (9,7%), almost half of these episodes would have been lost. These findings concur with the results of other studies [5, 6] suggesting that limiting follow-up to 30-days would cause several cases to be missed. In our view, the CDC scoring system should be used, but with a minimum follow-up time of 3 months (See Additional file 2).…”

“…These findings lend support to our proposal to extend post-discharge surveillance to a minimum of 3 months post-surgery, in order to avoid loss of cases. Interestingly, we found a higher rate of SSI-CRAN caused by E. cloacae than other studies [2, 4, 5, 7, 8, 17]. It should be noted that E. cloacae is resistant to cefuroxime, the prophylactic antibiotic used at our institution; this microorganism is able to thrive in humid environments, including water and soil and particularly in healthcare settings.…”

“…To the best of our knowledge, this is the first study evaluating SSI-CRAN aetiologies according to surgical site. The most frequently isolated microorganisms were Gram-positive cocci, as seen in many previous studies [2, 4, 5, 7, 8, 17]. C. acnes has frequently been identified as a cause of delayed SSI-CRAN [25].…”

“…The incidence of surgical site infection after craniotomy (SSI-CRAN) ranges from 2.2 to 19.8% [1–6]. SSI-CRAN has potentially devastating consequences: it is associated with significant morbidity and requires complex treatment that often involves the removal of the bone flap and long-term antibiotic therapy [5, 7]. Indeed, SSI-CRAN is associated with longer hospital stay, significant health care costs, and non-negligible mortality [1].…”

Cranial bone flap resorption—pathological features and their implications for clinical treatment

“…The literature regarding a potential correlation between graft material and infection rate is inconsistent [1,3,17,19,20,22,24,38,42]. Matsuno et al describe a significant infection rate for titanium mesh compared to autologous bone flaps and PMMA [26].…”