Surgical antibiotic prophylaxis in Neurosurgery [Neurosurgery Wiki]

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====== Surgical antibiotic prophylaxis in Neurosurgery ======


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The [[prevention]] of [[post-neurosurgical meningitis]] with [[antibiotic]]s prior to neurosurgery should be emphasized in [[clinical practice]], and appropriate selection of antibiotics is necessary to prevent the occurrence of [[infection]] and inhibit the emergence of [[antibiotic-resistant bacteria]]
((Zheng G, Shi Y, Sun J, Wang S, Li X, Lv H, Zhang G. Effect of [[antibiotic prophylaxis]] in the [[prognosis]] of [[Post-neurosurgical meningitis]] [[patient]]s. Eur J Med Res. 2023 Oct 4;28(1):396. doi: 10.1186/s40001-023-01399-7. PMID: 37794524.)).
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===== Choice =====

The choice of [[antibiotic]]s depends on the type of surgery, the likely [[pathogen]]s involved, and local [[antibiotic resistance]] patterns. Commonly used antibiotics include [[cefazolin]], [[cefoxitin]], and [[ceftriaxone]]. In some cases, a combination of antibiotics may be recommended.
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Patient-specific Factors: Consideration should be given to patient-specific factors, such as [[allergy]], renal and hepatic function, and the presence of comorbidities. Adjustments to the choice and dosage of antibiotics may be necessary based on individual patient characteristics.


===== Timing =====

Antibiotics should be administered shortly before the surgical incision, typically within 60 minutes before the start of the [[procedure]]. This helps ensure adequate antibiotic levels in the body tissues at the time of incision.

This timing ensures that the antibiotic reaches effective concentrations in the tissues when the incision is made and during the early stages of the procedure.

===== Dosing =====

Intraoperative Dosing: For prolonged surgeries or those with significant blood loss, additional doses of antibiotics may be required during the operation to maintain effective drug levels.

Prophylactic antibiotics are usually discontinued within 24 hours after surgery. Prolonged postoperative antibiotic use is generally not recommended as it does not reduce infection rates and can increase the risk of antibiotic resistance and other complications.

[[Redosing]]: In procedures lasting longer than the half-life of the chosen antibiotic, a redosing strategy may be necessary to maintain therapeutic levels. Redosing may be required for prolonged surgeries or procedures with significant blood loss.

Weight-Based Dosing: The dose of the antibiotic may be adjusted based on the patient's weight, especially in obese patients, to ensure adequate tissue concentrations.
Renal Function: Dosage adjustments may also be necessary for patients with impaired renal function to avoid toxicity.




===== Selection =====




[[Duration]]: The duration of prophylactic antibiotics is typically limited to the perioperative period, usually within 24 hours after surgery. Prolonged use of antibiotics increases the risk of resistance and other adverse effects.





Local Resistance Patterns: Knowledge of local bacterial resistance patterns is essential to guide the selection of appropriate antibiotics. Hospitals may have guidelines or protocols in place to help healthcare providers make informed decisions.

[[Monitoring]] and Evaluation: Regular monitoring of patients for signs of infection and adverse reactions to antibiotics is crucial. If a [[surgical site infection]] occurs, appropriate diagnostic tests should be performed to identify the causative microorganism and guide targeted therapy.

Multidisciplinary Approach: Collaboration between surgeons, anesthesiologists, pharmacists, and infectious disease specialists can help develop and implement effective antibiotic prophylaxis protocols.

It's important to note that antibiotic prophylaxis is not recommended for all surgical procedures. It is generally reserved for procedures associated with a higher risk of infection, such as clean-contaminated and contaminated surgeries. The decision to use prophylactic antibiotics should be based on a thorough assessment of the specific surgical context and patient characteristics.

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Perioperative [[antibiotic prophylaxis]] refers to the administration of antibiotics to patients before, during, and sometimes after surgery to prevent surgical site infections (SSIs). These infections are one of the most common complications after surgery and can lead to increased morbidity, extended hospital stays, and additional healthcare costs. The goal of perioperative antibiotic prophylaxis is to reduce the risk of infection by ensuring adequate levels of antibiotics in the tissues at the time of potential contamination.

Key Principles of Perioperative Antibiotic Prophylaxis:
Timing of Administration:


Choice of Antibiotic:

Spectrum of Activity: The chosen antibiotic should have activity against the most common pathogens associated with SSIs for the specific type of surgery. For many procedures, cefazolin (a first-generation cephalosporin) is commonly used due to its broad activity against skin flora, including Staphylococcus aureus and Streptococci.
Patient Factors: The choice of antibiotic may be adjusted based on patient-specific factors such as allergies (e.g., to penicillin or cephalosporins), local resistance patterns, and the presence of specific risk factors for infection by certain pathogens.
Type of Surgery: Different surgical procedures have different risk profiles and common pathogens. For example:
Clean surgeries (e.g., orthopedic, cardiac): Cefazolin is commonly used.
Clean-contaminated surgeries (e.g., gastrointestinal, gynecological): Additional coverage for gram-negative bacteria and anaerobes might be required, such as with a combination of cefazolin and metronidazole.
Contaminated or dirty surgeries: These situations might require broader-spectrum antibiotics or therapeutic doses instead of prophylaxis.


Minimizing Resistance: Appropriate use of perioperative antibiotics is crucial in minimizing the development of antibiotic resistance. This includes avoiding unnecessary use, selecting narrow-spectrum antibiotics when possible, and adhering to guidelines on timing and duration.
Local Guidelines: Hospitals and surgical centers often have protocols based on local microbial resistance patterns and infection rates, which guide the selection and administration of antibiotics for specific procedures.
Commonly Used Antibiotics:

Cefazolin: Frequently used for a wide range of procedures due to its effectiveness against common skin flora.
Vancomycin: Used in patients with a history of MRSA (Methicillin-resistant Staphylococcus aureus) colonization or in settings with a high prevalence of MRSA.
Clindamycin: An alternative for patients allergic to beta-lactams (penicillins and cephalosporins).
Metronidazole: Often added to cover anaerobes in surgeries involving the gastrointestinal tract.
Evaluation of Effectiveness:

Monitoring Outcomes: The effectiveness of perioperative antibiotic prophylaxis is often evaluated by monitoring the rate of SSIs, adherence to prophylaxis protocols, and the incidence of antibiotic-related adverse effects.
Quality Improvement: Data on infection rates and antibiotic use can be used for continuous quality improvement in surgical practice, ensuring that guidelines are up-to-date and reflect the best evidence.
Summary:
Perioperative antibiotic prophylaxis is a critical strategy to prevent surgical site infections. It involves the timely administration of appropriately chosen antibiotics, typically starting within 30 to 60 minutes before surgery, with the goal of achieving effective tissue concentrations during the operation. The choice of antibiotic depends on the type of surgery, the patient’s health status, and local resistance patterns. Proper use of prophylaxis helps minimize the risk of infection while also reducing the likelihood of antibiotic resistance and other complications.

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Decolonization in the medical context refers to the process of removing or reducing the presence of potentially harmful bacteria from a person's body, typically from areas like the skin or nasal passages. This is often done to prevent infections or reduce the risk of spreading harmful bacteria. 

===== Purpose =====

Reduce risk of infection in patients
Prevent transmission of bacteria to others
Prepare patients for medical procedures


===== Common target organisms =====

Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-resistant Enterococci (VRE)
Carbapenem-resistant Enterobacteriaceae (CRE)


===== Common sites for decolonization =====

Nasal passages
Skin (especially in high-risk areas like the groin and axilla)
Throat
Digestive tract


===== Methods of decolonization =====

Topical antibiotics (e.g., mupirocin for nasal decolonization)
Antiseptic body washes (e.g., chlorhexidine)
Oral antibiotics (in some cases)
Specialized mouthwashes


Settings where decolonization is often used:

Hospitals, especially intensive care units
Long-term care facilities
Pre-surgical preparation


===== Challenges =====

Bacterial resistance to decolonization agents
Recolonization after treatment
Compliance with multi-step protocols


===== Effectiveness =====

Can significantly reduce infection rates in healthcare settings
May need to be repeated periodically in some cases

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A [[guideline]] panel reviewed the impact of decolonization, targeted [[perioperative antibiotic prophylaxis]] (PAP), and combined interventions (e.g., [[decolonization]] and targeted PAP) on the risk of [[surgical site infection]]s (SSIs)  and other outcomes in multidrug-resistant [[Gram-positive bacteria]] (MDR-GPB) carriers, according to the type of [[bacteria]] and type of surgery.

They recommend [[screening]] for [[Staphylococcus aureus]] (SA) before high-risk operations, such as cardiothoracic and orthopedic surgery. [[Decolonization]] with intranasal [[mupirocin]] with or without [[chlorhexidine]] bathing is recommended in patients colonized with SA before cardiothoracic and orthopedic surgery and suggested in other surgeries. Addition of [[vancomycin]] to standard [[prophylaxis]] is suggested for [[MRSA]] carriers in cardiothoracic surgery, orthopedic surgery, and neurosurgery. Combined interventions (e.g., decolonization and targeted prophylaxis) are suggested in MRSA carriers undergoing cardiothoracic and orthopedic surgery. No [[recommendation]] could be made regarding screening, [[decolonization]], and targeted [[prophylaxis]] for [[vancomycin]]-resistant [[enterococci]] (VRE), due to the lack of data. 

No evidence was retrieved for  [[methicillin]]-resistant coagulase-negative [[staphylococci]] (MR-CoNS) and pan-drug-resistant (PDR)-GPB. Careful consideration of the laboratory [[workload]] and involvement of [[antimicrobial]] stewardship as well as [[infection]] control [[team]]s are warranted before implementing [[screening]] procedures or performing changes in PAP [[policy]]. Future research should focus on novel decolonizing techniques, on the [[monitoring]] of resistance to decolonizing agents and PAP regimens, and on standardized combined interventions in high-quality studies
((Righi E, Mutters NT, Guirao X, Dolores Del Toro M, Eckmann C, Friedrich AW, Giannella M, Presterl E, Christaki E, Cross ELA, Visentin A, Sganga G, Tsioutis C, Tacconelli E, Kluytmans J. ESCMID/EUCIC clinical guidelines on preoperative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria before surgery. Clin Microbiol Infect. 2024 Aug 16:S1198-743X(24)00341-0. doi: 10.1016/j.cmi.2024.07.012. Epub ahead of print. PMID: 39154859.))
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[[Surgical antibiotic prophylaxis]] in [[neurosurgery]] is an important [[practice]] aimed at preventing [[surgical site infection]]s (SSIs) and minimizing the risk of [[postoperative complication]]s. [[Neurosurgical procedures]] involve the manipulation of the [[central nervous system]], and [[infection]]s in this area can lead to serious consequences. 

===== Considerations =====

Duration of [[Prophylaxis]]: Prophylactic antibiotics are generally administered as a single preoperative dose. Prolonged use of antibiotics is generally not recommended to reduce the risk of antibiotic resistance unless there are specific considerations such as prolonged surgery or a high risk of infection.

Consideration of [[Blood-Brain Barrier]]: The choice of antibiotics in neurosurgery should take into account the blood-brain barrier. Not all antibiotics effectively penetrate the central nervous system, so selecting antibiotics with good penetration is essential.

Patient-Specific Factors: Patient-specific factors, such as allergies, renal and hepatic function, and comorbidities, should be considered when choosing and dosing antibiotics.


Collaboration with Infectious Disease Specialists: Collaboration with infectious disease specialists can be beneficial in developing and implementing effective antibiotic prophylaxis protocols. They can guide local resistance patterns and help optimize antibiotic choices.

Preventing [[Hypothermia]]: Maintaining normothermia during neurosurgery is important, as hypothermia can increase the risk of surgical site infections. Using appropriate warming devices can help prevent hypothermia.

Aseptic Techniques: Strict adherence to aseptic techniques during surgery, including proper [[sterilization]] of [[instrument]]s and maintaining a [[sterile]] field, is crucial in preventing infections.

It's important to note that neurosurgical prophylaxis may differ from prophylactic regimens used in other surgical specialties. [[Neurosurgeon]]s, in collaboration with [[infectious disease]] specialists and other relevant healthcare professionals, should establish and follow institution-specific protocols based on the latest evidence and guidelines. The goal is to balance the prevention of SSIs with the judicious use of antibiotics to minimize the risk of antibiotic resistance.

===== Principles of Antibiotic Prophylaxis Policy =====

Timing of antibiotic(s):

Optimum timing is intravenous dose given or infusion completed  60 minutes before skin incision

Sub-optimal if >1 hour before skin incision or post-skin incision
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Recording of antibiotic prescription in the ‘once only’ section of the medicine chart to avoid multiple dosing
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The frequency of administration should be a single dose only unless:

1.5 liters intra-operative blood loss re-dose following fluid replacement

operation prolonged

===== Choice of Antibiotics =====

[[Antibiotics for surgical site infection prevention]]

===== Risk =====

Because of a low risk of [[infection]]s in [[neurosurgery]] (around 2-3%), [[antibiotic prophylaxis]] is a controversial issue. 

Some neurosurgeons consider that there are strong arguments against the use of antimicrobials (promotion of antibiotic-resistant strains of bacteria, superinfection, and adverse drug reactions) and meticulous aseptic techniques could be more useful than prophylactic antibiotics. On the other hand, despite being rare, the consequences of a neurosurgical infection can be dramatic and may result in a rapid death, caused by meningitis, cerebritis, abscess formation, or sepsis. Clinical studies emphasized that the most important factors influencing the choice of antibiotic prophylaxis in neurosurgery are the patient's immune status, the virulence of the pathogens, and the type of surgery ("clean-contaminated"--a procedure that crosses the cranial sinuses, "clean non-implant"--a procedure that does not cross the cranial sinuses, CSF shunt surgery, skull fracture). Prophylaxis has become the standard of care for contaminated and clean-contaminated surgery, as well as for surgery involving the insertion of artificial devices. The antibiotic (first/second generation of cephalosporins or vancomycin in allergic patients) should recover only the cutaneous possibly contaminating flora (S. aureus, S. epidermidis) and should be administrated 30' before the surgical incision, intravenously in a single dose. Most studies pointed out that identification of the risk factors for infections, correct asepsis, and minimal prophylactic antibiotic regimen, help neurosurgeons improve patient care and decrease mortality without selecting resistant bacteria
((Iacob G, Iacob S, Cojocaru I. Profilaxia cu antibiotice în neurochirurgie [Prophylactic antibiotics in neurosurgery]. Rev Med Chir Soc Med Nat Iasi. 2007 Jul-Sep;111(3):643-8. Romanian. PMID: 18293694.)).
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Neurosurgery began with the use of the antiseptic [[hexamine]] in [[1925]] and has continued till the present with the introduction of new drugs from [[penicillin]] to [[vancomycin]]
((Savitz SI, Rivlin MM, Savitz MH: The ethics of prophylactic antibiotics for neurosurgical procedures. J Med Ethics 28: 358-363, 2002)).
Although clean neurosurgical procedures without implantation of foreign devices carry a low risk of postoperative infection, yet the application of prophylactic antibiotics is now routine in neurosurgery. This fact was supported by the results of multiple published studies
((Choux M, Genitori L, Lang D, Lena G: Shunt implantation: Reducing the incidence of shunt infection. J Neurosurg 77:875-880, 1992))
((Erman T, Demirhindi H, Iskender Gocer A, Tuna M, Ildan F, Boyar B: Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis. Surg Neurol 63:107-113, 2005)).

===== Cost-effectiveness =====

Very little data about the cost-effectiveness of the appropriate duration of antibiotic prophylaxis in low- and middle-income countries is available. 

A cost-analysis study demonstrates that prolonged antibiotic prophylaxis correlates with an increased burden of cost, but it is not preventive for SSI
((Ulu-Kilic A, Alp E, Cevahir F, Tucer B, Demiraslan H, Selçuklu A, Doğanay M.
Economic evaluation of appropriate duration of antibiotic prophylaxis for
prevention of neurosurgical infections in a middle-income country. Am J Infect
Control. 2015 Jan 1;43(1):44-7. doi: 10.1016/j.ajic.2014.09.010. PubMed PMID:
25564123.)).


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Administration of parenteral antibiotics before surgery reduces the incidence of postoperative infections after neurosurgical procedures, especially in cases with increased risk factors for SSI, such as ACA score of ≥ 2/3, the duration of the surgical intervention ≥ 4 hours, contaminated wound, and comorbidities. Perioperative [[antibiotic prophylaxis]] should be directed to better coverage of the S.aureus arrays.
((Dimovska-Gavrilovska A, Chaparoski A, Gavrilovski A, Milenkovikj Z. The
Importance of Perioperative Prophylaxis with Cefuroxime or Ceftriaxone in the
Surgical Site Infections Prevention after Cranial and Spinal Neurosurgical
Procedures. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2017 Sep 1;38(2):85-97. 
doi: 10.1515/prilozi-2017-0026. PubMed PMID: 28991759.
)). 
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Since the pioneering study of Mallis
((Malis LI: Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 5:339-343, 1979))
who reported the beneficial effects of local and [[preoperative antibiotic prophylaxis]] in clean neurosurgical wound infection, many randomized and meta-analysis studies confirmed the benefit of [[antibiotic prophylaxis]] in reducing the incidence of surgical site infection
((Barker FG 2nd: Efficacy of prophylactic antibiotics for craniotomy: A meta-analysis. Neurosurgery 35:484-490, 1994))
((Barker FG 2nd: Efficacy of prophylactic antibiotic therapy in spinal surgery: A meta-analysis. Neurosurgery 51:391-401, 2002))
((Bullock R, van Dellen JR, Ketelby W, Reinach SG: A double-blind placebo-controlled trial of perioperative prophylactic antibiotics for elective neurosurgery. J Neurosurg 69:687-691, 1988))
((Ingham HR, Kalbag RM, Sisson PR, Allcutt DA, Betty MJ, Crawford PJ, Gillham NR, Hankinson J, Sengupta RP, Strong AJ, Sinar EJ, Crone PB, Gillham M, Gould FK, Hudson SJ, Wardle JK, Cartmill TDI, Strokes ER: Simple perioperative antimicrobial chemoprophylaxis in elective neurosurgical procedures. J Hosp Infect 12: 225-233, 1988))
((Lietard C, Thébaud V, Besson G, Lejeune B: Risk factors for neurosurgical site infections: An 18 month prospective study. J Neurosurg 109:729-734, 2008)).

===== Protocols =====

The [[protocol]] of [[antibiotic prophylaxis]] is different among centers and the majority of previous publications came from The United States or Europe and rarely from [[developing countries]]. 
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The available evidence to assess the effect of wearing additional gloves, intraoperative glove change, or type of gloves on SSI rates is very limited and of low quality. The findings indicate the need for RCTs on this topic
((http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4474873/)).
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[[Double gloving]] is the practice of wearing two layers of medical gloves to reduce the danger of infection from glove failure or penetration of the gloves by sharp objects during medical procedures. A systematic review of the literature has shown double gloving to offer significantly more protection against inner glove perforation in surgical procedures compared to the use of a single glove layer
((Tanner, J; Parkinson, H (2002). "Double gloving to reduce surgical cross-infection". The Cochrane Library (3): CD003087. doi:10.1002/14651858.CD003087. PMID 12137673.))
((Tanner, J; Parkinson, H (2006). "Double gloving to reduce surgical cross-infection". The Cochrane Library (3): CD003087. doi:10.1002/14651858.CD003087.pub2)).
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The local application of powdered [[vancomycin]] was not associated with a significant difference in the rate of deep SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder.Level of Evidence: 2 ((Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, Kuchibhatla
M, Gottfried ON. Experience with intrawound vancomycin powder for spinal
deformity surgery. Spine (Phila Pa 1976). 2014 Jan 15;39(2):177-84. doi:
10.1097/BRS.0000000000000071. PubMed PMID: 24158179.)).
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[[Drain tip culture]] had a high positivity rate in the SSI group and the coincidence rate for the causative pathogen was relatively high
((Kawabata A, Sakai K, Sato H, Sasaki S, Torigoe I, Tomori M, Yuasa M, Matsukura
Y, Arai Y. Methicillin-resistant Staphylococcus Aureus Nasal Swab and Suction
Drain Tip Cultures in 4573 Spinal Surgeries: Efficacy in Management of Surgical
Site Infections. Spine (Phila Pa 1976). 2017 Aug 1. doi:
10.1097/BRS.0000000000002360. [Epub ahead of print] PubMed PMID: 28767628.
)).

===== GADSA gamified decision support app =====
The GADSA gamified decision support app uses WHO and Sanford prescribing guidelines to deliver real-time persuasive technology feedback to surgeons through an interactive mentor. The app can advise on whether clinician's decisions align with SAP recommendations and provides the opportunity for clinicians to make adjustments. Twenty surgeons actively participated in a 6-month pilot study in three hospitals in Nigeria. The surgeons determined the risk of infection of a surgical procedure, and the need, type and duration of SAP. The study used a longitudinal approach to test whether the GADSA app significantly changed prescribing behaviour of participating surgeons by analysing the reported prescription decisions within the app.

Results: 321 SAP prescriptions were recorded. Concerning the surgical risk decision, 12% of surgeons changed their decision to be in line with guidelines after app feedback (p < 0.001) and 10% of surgeons changed their decision about the need for SAP (p = 0.0035) to align with guidelines. The change in decision making for SAP use in terms of "type" and "duration" to align with guidelines was similar with 6% and 5% respectively (both p-values < 0.001).

Conclusion: This study suggests that the GADSA app, with its game based and feedback feature, could significantly change prescribing behaviour at the point of care in an African setting, which could help tackle the global challenge of antibiotic resistance
((Luedtke S, Wood C, Olufemi O, Okonji P, Kpokiri EE, Musah A, Bammeke F, Mutiu B, Ojewola R, Bankole O, Ademuyiwa A, Ekumankama C, Theophilus A, Aworabhi-Oki N, Shallcross L, Molnar A, Wiseman S, Hayward A, Birjovanu G, Lefevre C, Petrou S, Ogunsola F, Kostkova P. Gamified antimicrobial decision support app (GADSA) changes antibiotics prescription behaviour in surgeons in Nigeria: a hospital-based pilot study. Antimicrob Resist Infect Control. 2023 Dec 6;12(1):141. doi: 10.1186/s13756-023-01342-9. PMID: 38053212.)).
===== Pediatric antibiotic prophylaxis =====

see [[Pediatric antibiotic prophylaxis]].

===== Intraventricular antibiotic =====

[[Intraventricular antibiotic]].

===== Prolonged Antibiotic Use =====

see [[Ventriculostomy related infection prevention]].
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Prolonged [[antibiotic prophylaxis]], while the [[EVD]] is in place, does not decrease the [[risk]] of [[infection]] and
may select for resistant organisms. However, one dose pre-procedure antimicrobial may be administered.
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Prophylactic systemic antibiotics, while drains are in place, are frequently used to reduce [[surgical site infection]] rate (SSIR), though the practice remains controversial.
Pivazyan et al. demonstrated a two-fold reduction of SSI with the implementation of the PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery. Level of evidence: 3
((Pivazyan G, Mualem W, D'Antuono MR, Dowlati E, Nair N, Mueller KB. The utility of prolonged prophylactic systemic antibiotics (PPSA) for subfascial drains after degenerative spine surgery. Spine (Phila Pa 1976). 2021 Mar 11. doi: 10.1097/BRS.0000000000004031. Epub ahead of print. PMID: 33710111.)).

For Abola et al. there was no difference in the rate of surgical site infections between patients who received 24 hours of postoperative antibiotics and those who did not. Additionally, they found no observable risks, such as more antibiotic-resistant infections and C. difficile infections, with prolonged antibiotic use
((Abola MV, Lin CC, Lin LJ, Schreiber-Stainthorp W, Frempong-Boadu A, Buckland AJ, Protopsaltis TS. Postoperative Prophylactic Antibiotics in Spine Surgery: A Propensity-Matched Analysis. J Bone Joint Surg Am. 2021 Feb 3;103(3):219-226. doi: 10.2106/JBJS.20.00934. PMID: 33315695.)).
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Prolonged [[antibiotic]]s in [[neonate]]s with negative [[blood culture]] were associated with significantly longer hospital [[length of stay]] and increased total [[cost]] of [[hospitalization]]
((Sourour W, Sanchez V, Sourour M, Burdine J, Lien ER, Nguyen D, Jain SK. The Association between Prolonged Antibiotic Use in Culture Negative Infants and Length of Hospital Stay and Total Hospital Costs. Am J Perinatol. 2021 May 11. doi: 10.1055/s-0041-1729560. Epub ahead of print. PMID: 33975363.)).

===== Antibiotic-impregnated catheter =====

[[Antibiotic-impregnated catheter]].

===== Antibiotics for Brain Abscess =====


see [[Antibiotics for Brain Abscess]].

===== Case series =====
A [[cohort]] analysis was performed using the clinical [[database]] in Beijing Tiantan Hospital and Capital Medical University. Data were collected on patients with the diagnosis of post-neurosurgical [[meningitis]] (n = 3931) during 2012.01 to 2022.04. The microbial distribution, types of [[antibiotic prophylaxis]], and 42 and 90 days survival analysis of AP patients were evaluated using probable statistical methods. Independent risk factors for mortality were established by constructing a logistic regression analysis.

A total of 1,190 patients were included in this study, Klebsiella pneumoniae, Acinetobacter baumannii, and Staphylococcus aureus occupied the highest proportion. Of them, 929 cases received AP, cefuroxime and ceftriaxone are the most frequent used antibiotics. In addition, We found that PNM patients without AP significantly increased the 42 days and 90 days all-cause mortality rates. The use of different levels of AP did not improve patient outcomes, and ICU admission and assisted mechanical ventilation (AMV) were identified as independent mortality risk factors for PNM patient received AP.

AP plays an important role in the prognosis of PNM patients and has a significant function in improving prognosis. The prevention of PNM with antibiotics prior to neurosurgery should be emphasized in clinical practice, and appropriate selection of antibiotics is necessary to prevent the occurrence of infection and inhibit the emergence of antibiotic-resistant bacteria
((Zheng G, Shi Y, Sun J, Wang S, Li X, Lv H, Zhang G. Effect of antibiotic prophylaxis in the prognosis of Post-neurosurgical meningitis patients. Eur J Med Res. 2023 Oct 4;28(1):396. doi: 10.1186/s40001-023-01399-7. PMID: 37794524.)).

===== Survey =====
Antibiotic prophylaxis practices in neurosurgery: A Society for Healthcare Epidemiology of America (SHEA) survey
((Sastry RA, Wang EJ, Mermel LA. Antibiotic prophylaxis practices in neurosurgery: A Society for Healthcare Epidemiology of America (SHEA) survey. Infect Control Hosp Epidemiol. 2021 Dec 17:1-2. doi: 10.1017/ice.2021.488. Epub ahead of print. PMID: 34915964.)).