Departments of1Medicine.
2Neurosurgery, and.
J Neurosurg. 2023 Aug 18;140(3):892-899. doi: 10.3171/2023.6.JNS23751. Print 2024 Mar 1.
The primary aim of this retrospective study was to assess differences in the pathogens causing surgical site infections (SSIs) following craniectomies/craniotomies and open spinal surgery. The secondary aim was to assess differences in rates of SSI among these operative procedures.
ANOVA tests with Bonferroni correction and incidence risk ratios (RRs) were used to identify differences in pathogens by surgical site and procedure using retrospective, de-identified records of 19,993 postneurosurgical patients treated between 2007 and 2020.
The overall infection rates for craniotomy/craniectomy, laminectomy, and fusion were 2.1%, 1.1%, and 1.5%, respectively, and overall infection rates for cervical, thoracic, and lumbar spine surgery were 0.3%, 1.6%, and 1.9%, respectively. Craniotomy/craniectomy was more likely to result in an SSI than spine surgery (RR 1.8, 95% CI 1.4-2.2, p < 0.0001). Cutibacterium acnes (RR 24.2, 95% CI 7.3-80.0, p < 0.0001); coagulase-negative staphylococci (CoNS) (methicillin-susceptible CoNS: RR 2.9, 95% CI 1.6-5.4, p = 0.0006; methicillin-resistant CoNS: RR 5.6, 95% CI 1.4-22.3, p = 0.02); Klebsiella aerogenes (RR 6.5, 95% CI 1.7-25.1, p = 0.0003); Serratia marcescens (RR 2.4, 95% CI 1.1-7.1, p = 0.01); Enterobacter cloacae (RR 3.1, 95% CI 1.2-8.1, p = 0.02); and Candida albicans (RR 3.9, 95% CI 1.2-12.3, p = 0.02) were more commonly associated with craniotomy/craniectomy cases than fusion or laminectomy SSIs. Pseudomonas aeruginosa was more commonly associated with fusion SSIs than craniotomy SSIs (RR 4.4, 95% CI 1.3-14.8, p = 0.02), whereas Escherichia coli was nonsignificantly associated with fusion SSIs compared to craniotomy SSIs (RR 4.1, 95% CI 0.9-18.1, p = 0.06). Infections with E. coli and P. aeruginosa occurred primarily in the lumbar spine (p = 0.0003 and p = 0.0001, respectively).
SSIs due to typical gastrointestinal or genitourinary gram-negative bacteria occur most commonly following lumbar surgery, particularly fusion, and are likely to be due to contamination of the surgical bed with microbial flora in the perianal area and genitourinary tract. Cutibacterium acnes in the skin flora of the head and neck increases risk of infection due to this microbe following surgical interventions in these body sites. The types of gram-negative bacteria associated with craniotomy/craniectomy SSIs suggest potential environmental sources of these pathogens. Based on the authors' findings, neurosurgeons should consider using a two-step skin preparation with benzoyl peroxide, in addition to a standard antiseptic such as alcoholic chlorhexidine for cranial, cervical, and upper thoracic surgeries. Additionally, broader gram-negative bacterial coverage, such as use of a third-generation cephalosporin, should be considered for lumbar/lumbosacral fusion surgical antibiotic prophylaxis.
本回顾性研究的主要目的是评估颅骨切开术/开颅术和开放性脊柱手术后手术部位感染（SSI）的病原体差异。次要目的是评估这些手术程序之间 SSI 发生率的差异。
使用回顾性、去识别的记录，评估 2007 年至 2020 年间治疗的 19993 名神经外科后患者的手术部位和手术的病原体差异，采用方差分析检验和 Bonferroni 校正以及发病率风险比（RR）。
颅骨切开术/开颅术、椎板切除术和融合的总体感染率分别为 2.1%、1.1%和 1.5%，颈椎、胸椎和腰椎手术的总体感染率分别为 0.3%、1.6%和 1.9%。颅骨切开术/开颅术比脊柱手术更有可能导致 SSI（RR 1.8，95%CI 1.4-2.2，p<0.0001）。痤疮丙酸杆菌（RR 24.2，95%CI 7.3-80.0，p<0.0001）；凝固酶阴性葡萄球菌（CoNS）（甲氧西林敏感 CoNS：RR 2.9，95%CI 1.6-5.4，p=0.0006；甲氧西林耐药 CoNS：RR 5.6，95%CI 1.4-22.3，p=0.02）；肺炎克雷伯菌（RR 6.5，95%CI 1.7-25.1，p=0.0003）；粘质沙雷氏菌（RR 2.4，95%CI 1.1-7.1，p=0.01）；阴沟肠杆菌（RR 3.1，95%CI 1.2-8.1，p=0.02）；和白色念珠菌（RR 3.9，95%CI 1.2-12.3，p=0.02）与颅骨切开术/开颅术病例比融合或椎板切除术 SSI 更常见。铜绿假单胞菌与融合 SSI 比颅骨切开术 SSI 更常见（RR 4.4，95%CI 1.3-14.8，p=0.02），而大肠埃希菌与融合 SSI 比颅骨切开术 SSI 无显著相关性（RR 4.1，95%CI 0.9-18.1，p=0.06）。大肠埃希菌和铜绿假单胞菌感染主要发生在腰椎（p=0.0003 和 p=0.0001）。
胃肠道或泌尿生殖道革兰氏阴性菌引起的 SSI 最常见于腰椎手术后，特别是融合术，很可能是由于手术床污染了肛周和泌尿生殖道的微生物菌群。头颈部皮肤菌群中的痤疮丙酸杆菌会增加这些部位手术感染的风险。与颅骨切开术/开颅术 SSI 相关的革兰氏阴性菌类型提示这些病原体可能存在环境来源。根据作者的发现，神经外科医生应考虑在颅骨、颈椎和上胸椎手术中使用两步式过氧化苯甲酰皮肤准备，外加标准的抗菌剂如酒精洗必泰。此外，对于腰椎/腰骶部融合手术的抗生素预防，应考虑更广泛的革兰氏阴性菌覆盖，如使用第三代头孢菌素。
