Nguyen Anthony V, Coggins William S, Jain Rishabh R, Branch Daniel W, Allison Randall Z, Maynard Ken, Oliver Brian, Lall Rishi R
School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA.
School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA.
Clin Neurol Neurosurg. 2019 Jul;182:152-157. doi: 10.1016/j.clineuro.2019.05.017. Epub 2019 May 19.
Cefazolin and vancomycin are common choices for neurosurgical antimicrobial prophylaxis. Cefazolin is typically first-line due to its lower toxicity profile and specificity for gram-positives such as skin commensals, while vancomycin is often reserved for patients with cephalosporin or penicillin allergies. However, one randomized clinical trial demonstrated superiority of vancomycin for cerebrospinal fluid (CSF) shunt insertions at a hospital with a high prevalence of methicillin-resistance Staphylococcus aureus (MRSA). We aimed to evaluate the association of prophylaxis choice and incidence of surgical site infection (SSI) at our own institution.
This was a retrospective cohort study of patients who underwent a neurosurgical operation from January 2013 to April 2016 at one particular hospital belonging to our institution. We included patients who received either only cefazolin or only vancomycin as their pre-incisional prophylaxis. Vancomycin was substituted for cefazolin in patients with known penicillin or cephalosporin allergy. Procedures requiring multiple attending surgeons were excluded. We defined a SSI as a confirmed culture isolated from the wound, implant (if pertinent), or CSF (if pertinent) within a year of surgery. Multivariable logistic regression was performed with consideration of antibiotic, operation performed, wound class, and procedure length.
A total of 859 operations met study criteria; 664 patients received Cefazolin, and 195 received Vancomycin. We identified 22 SSIs, with 14 in the cefazolin (2.2%) and 8 in the vancomycin (4.1%) group. Upon logistic regression, there was no significant association of vancomycin substitution with incidence of SSIs between the two groups (odds ratio, 1.59; 95% CI, 0.42-6.00, p = .49). In the cefazolin group, 8/14 cultures were positive for S. aureus compared to 1/8 of the vancomycin group.
There was no significant difference in neurosurgical site infection incidence when vancomycin prophylaxis was substituted for cefazolin. S. aureus was isolated from patients who received cefazolin at a higher rate although this was not statistically significant. At our institution, S. aureus makes up 36% of isolated organisms from inpatient and intensive care units. Institutions should consider their own investigations into local antibiograms, SSI rates, and choice of prophylaxis.
头孢唑林和万古霉素是神经外科抗菌预防的常用选择。头孢唑林通常作为一线用药，因为其毒性较低，且对革兰氏阳性菌（如皮肤共生菌）具有特异性，而万古霉素通常用于对头孢菌素或青霉素过敏的患者。然而，一项随机临床试验表明，在耐甲氧西林金黄色葡萄球菌（MRSA）患病率较高的医院，万古霉素用于脑脊液（CSF）分流术具有优势。我们旨在评估我们自己机构中预防用药选择与手术部位感染（SSI）发生率之间的关联。
这是一项对2013年1月至2016年4月在我们机构所属的一家特定医院接受神经外科手术的患者进行的回顾性队列研究。我们纳入了仅接受头孢唑林或仅接受万古霉素作为切口前预防用药的患者。已知对青霉素或头孢菌素过敏的患者用万古霉素替代头孢唑林。排除需要多名主治外科医生的手术。我们将SSI定义为在手术一年内从伤口、植入物（如适用）或脑脊液（如适用）中分离出的确诊培养物。在考虑抗生素、所进行的手术、伤口类别和手术时长的情况下进行多变量逻辑回归分析。
共有859例手术符合研究标准；664例患者接受头孢唑林，195例患者接受万古霉素。我们确定了22例SSI，头孢唑林组有14例（2.2%），万古霉素组有8例（4.1%）。经逻辑回归分析，两组之间万古霉素替代与SSI发生率无显著关联（比值比，1.59；95%置信区间，0.42 - 6.00，p = 0.49）。在头孢唑林组中，14份培养物中有8份金黄色葡萄球菌呈阳性，而万古霉素组为8份中的1份。
用万古霉素预防替代头孢唑林时，神经外科手术部位感染发生率无显著差异。接受头孢唑林治疗的患者分离出金黄色葡萄球菌的比例更高，尽管这在统计学上无显著意义。在我们机构，金黄色葡萄球菌占住院患者和重症监护病房分离出的微生物的36%。各机构应考虑自行调查当地的抗菌谱、SSI发生率和预防用药选择。
