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Antibiotic prophylaxis in craniotomy: A review

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Neurosurg Rev (2014) 37:407–414
DOI 10.1007/s10143-014-0524-z
REVIEW
Antibiotic prophylaxis in craniotomy: a review
Weiming Liu & Ming Ni & Yuewei Zhang & Rob J. M. Groen
Received: 24 November 2012 / Revised: 24 August 2013 / Accepted: 27 October 2013 / Published online: 13 February 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract The effectiveness of antibiotic prophylaxis (AP) in
craniotomies has been clarified through the accumulation of
evidence and increased antibiotic knowledge. This paper fo-
cuses on the use of AP in craniotomies during different
historical periods and collects highly relevant evidence on this
issue. This review surveys different AP guidelines and ex-
plains why cefazolin was selected by most guidelines. Recent
prominent topics, including strategies to update and imple-
ment guidelines and antibiotic efficacy in postoperative men-
ingitis and surveillance and decolonization therapies for
methicillin-resistant Staphylococcus aureus, are discussed.
Keywords Antibiotic prophylaxis . Craniotomy . Surgical site
infection . Guidelines . Cefazolin
Although the rate of surgical site infection (SSI) after craniot-
omy is known to be low, the routine use of antibiotic prophy-
laxis (AP) was adopted by many neurosurgeons because of the
potentially devastating consequences of infectious complica-
tions. The use of AP has been an ongoing issue throughout
different historical periods.
Weiming Liu and Ming Ni contributed equally to this paper.
W. Liu (*) : M. Ni
Department of Neurosurgery, Beijing Tiantan Hospital, Capital
Medical University, Tiantan Xili 6, 100050 Beijing, China
e-mail: dr_wmliu@hotmail.com
W. Liu : R. J. M. Groen
Department of Neurosurgery, University Medical Center Groningen,
University of Groningen, Hanzeplein 1, 9713 GZ Groningen,
Netherlands
Y. Zhang
Department of Hospital Infection Control, Beijing Tiantan Hospital,
Capital Medical University, Tiantan Xili 6, 100050 Beijing, China
Pre-1980s, exploration and debate
Early neurosurgeons were aware of postoperative infections.
Cushing said, “Certainly infections cannot be attributed to the
intervention of the devil but must be laid at the surgeon’s
door” [1]. People went to great lengths to avoid postoperative
infections. In the 1940s, after the refinement and production of
Alexander Fleming’s penicillin mold extract, AP served as a
more advanced form of antisepsis, further reducing postoper-
ative infections.
The first report on prophylactic antibiotics in neurosurgery
was provided by Hugh Cairns in 1947 [2]. Surgeons placed
penicillin powder directly onto patients’ brains during World
War II in London. The postoperative infection rate was 0.9 %
in the penicillin-treated patients, and this appeared to be lower
than the historical controls’ infection rate of 5.4 %. Although
this method of prophylactic antibiotic usage was not standard-
ized in today’s view, it was a good attempt.
With the increasing diversity of antibiotics, neurosurgeons
first chose antibiotics or combined antibiotic regimens with
broad antibacterial spectra for prophylaxis. They believed that
a “sterile” body could prevent postoperative infections. This
idea was prevalent for a long time. The general protocol
involved a combination of penicillin and streptomycin. Un-
fortunately, many tests in other surgical fields did not support
this method. In their general surgical cases, Sanchez-Ubeda
[3] and Rocha [4] found that AP with penicillin and strepto-
mycin showed no benefit and may have been associated with
an increased risk of infection. In neurosurgery, Wright [5]
tested the administration of penicillin and streptomycin after
craniotomies. The postoperative infection rate was 5.8 % in
the AP group and 5.5 % in the no-AP group. There was no
evidence that AP decreased the risk of infection.
There are two reasons for AP failure during this early
period. The first involves the timing of AP use, which was
not clear until Burke’s experiment [6]. Burke used guinea pigs
408
to mimic surgical incisions with Staphylococcus contamina-
tion. He found that the effective period begins the moment the
bacteria gain access to the tissue, which occurs within 3 h. He
suggested the use of systemic antibiotics before the bacteria
had gained access to the tissue. Alexander [7] tested penicillin
in staphylococcal surgical wound infections, and his results
supported Burke’s suggestion. Since then, it has been gradu-
ally accepted that AP should be used before surgery. The
second reason for AP failure was an ineffective categorization
of wounds. In 1964, the National Academy of Sciences—
United States National Research Council classified wounds
into four groups [8]: clean, clean–contaminated, contaminat-
ed, and dirty. This categorization provides a good distinction
between prevention in clean and clean–contaminated wounds
and treatment in contaminated and dirty wounds.
When these two issues were better understood, the subse-
quent experiments achieved many positive results. In Mount
Sinai Hospital, an intraoperative regimen of lincomycin was
used, and the infection rate decreased to 2.3 % [9]. Later, a
randomized, double-blind trial was performed to test the use
of short-term preoperative lincomycin [10]. This well-
designed trial was terminated unexpectedly because of a sud-
den epidemic of wound infections. This trial showed an in-
fection rate of 1 % in the lincomycin group and 9 % in the
placebo group, proving the efficacy of AP. In 1979, they
reported amazing results [11]. In the 1,732 consecutive neu-
rosurgical procedures, there was no evidence of postoperative
infections under the routine use of a single intraoperative dose
of gentamicin (tobramycin), vancomycin, and topical strepto-
mycin irrigating solution. This regimen was based on a review
of organisms cultured from infections throughout hospital
over the previous 5 years. When repeating this regimen,
Quartey did not obtain zero infections but still had a low
infection rate of 0.8 % [12].
Although the efficacy of AP in craniotomies has been
verified in some studies, some debate remains ongoing. Cer-
tain retrospective studies have shown that the use of prophy-
lactic antibiotics is not valid, regardless of which regimen is
used [13–15]. Even without AP, there can be a very low rate of
infection in craniotomies [16]. During the first randomized
control trial [10], the efficacy of prophylaxis was questioned
by Haines [17] because the majority of cases in an infection
epidemic fell into the no-AP group. Even in their own hospi-
tal, they stated after the infection epidemic that “Antibiotic
prophylaxis is not recommended. This may mask an ongoing
problem” [11].
Another controversy existed over determining whether a
clean wound required AP. Most craniotomies are clean
wounds, although a few fall into the clean–contaminated
(open paranasal sinuses or mastoid) subgroup. Some experts
believe that using AP in clean neurosurgery is not appropriate,
and there have been concerns about the side effects of wide-
spread antibiotics use, including antibiotic abuse, bacterial
Neurosurg Rev (2014) 37:407–414
spectrum changes, and increased resistance [18, 19]. These
problems remain a concern today.
The value of prophylactic antibiotics in craniotomies could
not be resolved with the data available before the 1980s. Most
neurosurgeons used AP because they feared the life-
threatening consequences of infection. A variety of AP regi-
mens were chosen, generally based on individual experience.
Some consensus was achieved during this period, as follows:
antibiotics should be used preoperatively; a short-term regi-
men or even a single dose can achieve good results; and
antibiotics should be chosen based on the spectrum of the
local infectious organisms. There was no doubt that rigorous
clinical trials were needed to validate the efficacy of AP.
1980s and 1990s: trials and guidelines
A few randomized controlled trials were performed in the
1980s and the early 1990s. All but one of these trials showed
that AP was more effective than a placebo for SSI. Table 1
shows the details of these trials.
Some of these trials had imperfections, such as early ter-
mination due to the outbreak of infection [20, 21], no placebo
given [22], no blinding [23], and a small sample size [20, 21,
24, 25]. Although these trials had flaws, they all met the basic
requirements for prospectively controlled trials and have pro-
vided the best evidence to date. It is ethically difficult to repeat
similar placebo-controlled studies today. All current AP
guidelines are drawn from these trials’ results. Among these
trials, only Rocca’s trial indicated that AP was ineffective [26].
In this trial, no infections occurred in the cefamandole pro-
phylaxis group or the placebo group. However, due to the
small sample size, the result does not carry strong weight.
In 1994, Barker used most of the previously discussed trials
to verify AP’s efficacy for craniotomies with a meta-analysis
[27]. He found 19 infections in 1,014 craniotomies with AP
and 93 infections in 1,061 craniotomies in the control group.
The analysis reflected an advantage of antibiotics over the
placebo at the P<10−8 level. After this analysis, the debate
about AP efficacy in craniotomies came to an end. Another
important result of this meta-analysis was that no differences
were found between the use of single or multiple doses in both
antibiotic regimens. This conclusion was very important for
the development of later guidelines. The “no difference” prin-
ciple indicates that there are no best antibiotics and that only
antibiotics consistent with the current antibiotic principles
should be selected.
Malis’ excellent results [11] led to this regimen being
repeated by Geraghty [22] and Shapiro [28]. The broad-
spectrum regimen included vancomycin for Gram-positive
bacteria and gentamicin for Gram-negative bacteria. Young
[29] also used a combined broad-spectrum regimen of
cefazolin (first-generation cephalosporin) and gentamicin.
Neurosurg Rev (2014) 37:407–414 409

Table 1 AP prospectively controlled trials include craniotomy information

Authors Year Reference Antibiotics Include patients Significance Reasons for antibiotic choice

Savitz 1976 [10] Clindamycin 60 Yes Previous users of lincomycin obtained

an infection rate of 2.3 %; this was
tested
Geraghty 1984 [22] Vancomycin, gentamicin, 114 Yes Followed Malis’ [11] regime
streptomycin (topical)
Shapiro 1986 [28] Vancomycin, gentamicin, 53 (tumors) Yes Followed Malis’ [11] regime
streptomycin (topical)
Young 1987 [29] Cefazolin, gentamicin 308 Yes Bacterial isolates and susceptibilities were
conducted in hospital
Blomstedt 1988 [23] Vancomycin 360 Yes Covers the most common agents causing
infections (although spectrum is narrow)
Bullock 1988 [69] Piperacillin 196 Yes Broad-spectrum activity; bactericidal effect;
effective passage through the blood–brain
barrier
Van Ek, Dijkmans 1988 [64] Cloxacillin 248 Yes Sensitive to most bacteria in retrospective
post-craniotomy infections; narrow
spectrum, less resistance
Djindjian 1990 [21] Oxacillin 216 Yes Previous efficacy experience in shunt
procedures
Gaillard 1991 [70] Cefotiam 661 Yes Broad-spectrum antibiotic; penetrates soft
tissue and bone; low toxicity and few side
effects
Rocca 1992 [26] Cefamandole 78 No Broad-spectrum antibiotic
Mindermann 1993 [43] Fusidic acid 38 Yes Safe; long serum half-life; high activity on
Gram-positive cocci

Later trials used only one antibiotic for prophylaxis, including
glycopeptide (vancomycin), penicillins (cloxacillin, oxacillin,
and piperacillin), or second-generation cephalosporins
(cefotiam and cefamandole).
After the 1980s, there was much excitement over the use of
these new antibiotics as a powerful tool to prevent infections.
As time passed, awareness regarding antibiotic side effects
increased, and these medications were used more carefully.
Here, we individually evaluate the current antibiotics used in
trials. For this purpose, AP can be categorized by the use of
broad-spectrum antibiotics or narrow-spectrum antibiotics.
Broad-spectrum antibiotics
Piperacillin is a third-generation penicillin with an extended
spectrum that is active against Gram-positive cocci, anaer-
obes, and Gram-negative bacteria. Piperacillin is effective at
penetrating into the cerebrospinal fluid to treat meningitis
[30]. Today, the piperacillin–tazobactam combination is wide-
ly used against Gram-negative bacilli.
Cefotiam and cefamandole are second-generation cephalo-
sporins. As a group, the second-generation cephalosporins are
less effective against Gram-positive microbes but more effec-
tive against Gram-negative microbes, including Haemophilus
influenzae, Enterobacter aerogenes, and certain Neisseria.
These can also be used as broad-spectrum antibiotics. Addi-
tionally, combined antibiotic regimens, such as Malis’ regi-
men, have been followed by many studies for their broad-
spectrum activities. In today’s view, the treatment and preven-
tion of craniotomy infections (e.g., meningitis) should use
different strategies, as inflamed meninges and normal menin-
ges have different permeabilities for antibiotics.
As research developed, broad-spectrum antibiotics were
not found to be a good choice for prophylaxis in craniotomies.
The main reason for this finding is that these antibiotics are
unnecessary. AP does not represent an attempt to sterilize
tissues. Rather, it is a critically timed adjunct used to reduce
the microbial burden of intraoperative contamination to a level
that cannot overwhelm the host’s defenses [31]. A prophylac-
tic regimen in patients undergoing surgery should include an
agent that is effective against the most likely organisms with-
out needing to eradicate every potential pathogen. In neuro-
surgery, Staphylococcus aureus is always a major pathogen,
arising from the skin flora; thus, the AP need not cover all of
the causative organisms. A second reason involves the side
effects of broad-spectrum antibiotics. Clostridium difficile-
associated diarrhea occurs more frequently when broad-
spectrum antibiotics are used [32, 33], and broad-spectrum
antibiotics increase the risk of resistant organisms [34]. Epi-
demiological investigations have confirmed this finding [35].
410
Therefore, piperacillin and other broad-spectrum antibiotics
are not suitable for prophylaxis. The current guidelines rec-
ommend narrow-spectrum AP for craniotomies.
Narrow-spectrum antibiotics
Gentamicin and tobramycin are aminoglycoside antibiotics.
Although aminoglycosides are active against Staphylococcus,
they are mostly used to treat Gram-negative bacterial infec-
tions [36]. An increased rate of Pseudomonas and Serratia
resistance to gentamicin has been detected [37]. Gentamicin
and tobramycin are ototoxic and nephrotoxic. Aminoglyco-
side therapy is currently more restricted and requires close
monitoring [38]. Most post-neurosurgery infections are
caused by Gram-positive bacteria, and aminoglycosides are
not recommended for prophylaxis either as single drugs or in
combination regimens [31].
Vancomycin was first used clinically in 1958. Shortly after
its introduction, vancomycin was eclipsed by antibiotics that
were considered to be less toxic and equally or more effica-
cious. In the early 1980s, a dramatic increase in vancomycin
use occurred because of the advent of pseudomembranous
enterocolitis and the spread of methicillin-resistant S. aureus
(MRSA) [39, 40]. Since then, the rate of vancomycin-resistant
enterococci (VRE) resistance in healthcare-associated infec-
tions increased from 0.3 % in 1989 to 7.9 % in 1991 [41]. The
use of vancomycin is a reported risk factor for infection and
colonization with VRE and may increase the possibility of the
emergence of vancomycin-resistant S. aureus or Staphylococ-
cus epidermidis [42]. The routine use of vancomycin antimi-
crobial prophylaxis is not recommended for any procedure
[31]. Vancomycin should only be used as AP in the following
circumstances: a history of a life-threatening allergic reaction
to penicillin or cephalosporins, a known history of MRSA
infection, or frequent MRSA wound infections.
Cloxacillin and oxacillin were chosen for Van Ek and
Djindjian’s trials. These compounds are semisynthetic peni-
cillins that appeared in the 1950s. They are narrow-spectrum
and penicillinase-resistant penicillin antibiotics that are only
used for the treatment of methicillin-sensitive S. aureus. Be-
cause of the rapid emergence of resistance, the use of these
two drugs has been gradually reduced in prophylactic
regimens.
Fusidic acid was chosen in Mindermann’s trial [43].
Fusidic acid is a unique member of the fusidane class of
antibiotics that has no known cross-resistance with any other
class of antibiotic [44]. Its safety has been clinically docu-
mented over more than 40 years [5, 45]. Its spectrum of
antimicrobial activity is narrow but sufficient for targeting
Staphylococcus (including MRSA) and β-hemolytic strepto-
cocci [46, 47]. The characteristics of fusidic acid indicate that
it complies with the requirements of AP, but no guidelines
recommend this drug. Until recent years, it was approved for
Neurosurg Rev (2014) 37:407–414
use in the USA and Canada [29, 48] for the treatment of
MRSA infections.
Cefazolin has been used clinically since 1970. Cefazolin is
a first-generation cephalosporin that is most active against
Gram-positive bacteria, methicillin-susceptible staphylococci,
and non-enterococcal streptococci. Cefazolin is mainly used
to treat bacterial infections of the skin because they are mainly
caused by Gram-positive staphylococci and streptococci.
These bacteria are the main cause of post-craniotomy infec-
tions originating from the colonizing flora of the skin incision
area. Cefazolin provides adequate coverage for many clean
and clean–contaminated operations [49].
There is no evidence that the newer antimicrobials are
better than older drugs. Antimicrobial selection is based on
cost, adverse effect profile, ease of administration, pharmaco-
kinetic profile, and antibacterial activity [50]. Table 2 lists the
characteristics of the ideal prophylactic antimicrobial drug,
which should have activity against the most common neuro-
surgical wound pathogens. Cefazolin should be the agent of
choice in craniotomies because of its demonstrated safety,
acceptable pharmacokinetics, and reasonable cost per dose
[51]. Several countries’ AP guidelines select cefazolin for
prophylaxis in craniotomies; the details are shown in Table 3.
The new century: facing new problems
In this new century, we are encountering more serious condi-
tions in antibiotics and pathogens. This scenario requires
strategies to be continuously developed to meet these
challenges.
Update and implementation guidelines
When considering the use of antimicrobial prophylaxis, we
must think about the development of antimicrobial resistance.
Today, we are faced with increasing bacterial resistance. The
rate of VRE resistance in healthcare-associated infections has
increased from 0.3 % in 1989 to 7.9 % in 1993 and 33 % in
2007 [24].
Although cefazolin is a good prophylactic agent for many
surgical procedures, it increases the likelihood of antimicro-
bial resistance [52]. Another factor that may discourage
cefazolin prophylaxis is that MRSA is resistant to all cepha-
losporins. Some articles in other specialties suggest changing
the AP regimen because of bacterial resistance [53] and side
effects [45].
In neurosurgery, S. aureus remains a major pathogen [54].
Cefazolin is still recommended in most current guidelines.
Vancomycin prophylaxis is controversial because of the in-
creased prevalence of MRSA. In prophylaxis for shunts [55],
intravenous and/or systemic administration [32, 56] has pro-
duced positive results. There is no strong evidence to support
Neurosurg Rev (2014) 37:407–414
Table 2 Characteristics of the ideal AP drug
Characteristics of the ideal AP drug
Necessary spectrum against the pathogens causing SSI
Adequate concentrations in operative site tissue
Half-life permits single-dose injection
Can be bolus injected with the induction of anesthesia
No adverse effects associated with short-term administration
Not allergenic
No interactions with perioperative drugs
Not an essential drug of the therapeutic arsenal
Not expensive
Revised from Gyssens [50] and the Scottish Intercollegiate Guidelines
Network [33]
vancomycin prophylaxis in craniotomies. Vancomycin can be
used only when a cluster or high rate of MRSA or methicillin-
resistant coagulase-negative staphylococci SSI has been de-
tected at an institution [18]. Another consideration is the use of
implants in craniotomies. Implants are a risk factor for SSIs
[14], and the increased use of implantation in neurosurgery
may call for further studies to confirm the role of vancomycin
prophylaxis in implantation.
Implementing the current guidelines remains challenging.
The rate of adherence to AP guidelines was not satisfactory in
the Netherlands [57]. In the USA, a survey found that approx-
imately half of cases were in full compliance with the guide-
lines [15]. In the UK, cases in which doctors failed to prescribe
antibiotics were associated with SSI [58]; Japan faces the
same problem [59]. Even in Germany, the use of antimicrobial
prophylaxis in the clinical settings has been recently
Table 3 AP guidelines about craniotomy in several countries
Country Organization Update Reference Recommended antibiotics
year
USA The American Society of Health- 1999
System Pharmacists
USA Centers for Disease Control and 1999
Prevention
Netherlands The Dutch Foundation of the Working 1999
Party on Antibiotic Policy (SWAB)
Japan Japanese Society of Chemotherapy and 2001
The Japanese Association for
Infection Diseases
UK Scottish Intercollegiate Guidelines 2008
Network
USA Institute for Clinical Systems 2010
Improvement
Germany Expert commission of the Paul Ehrlich 2010
Society for Chemotherapy (PEG)
411
associated with inappropriate timing, selection, and an exces-
sive duration of antibiotic administration [25]. These studies
noted that surgeons were accustomed to making decisions
based on their own experience, and it was counterintuitive
for them to accept AP guidelines.
Guideline implementation must be supported by various
types of programs, including continuing education, evaluation
of the current literature, and regular examinations of antibiotic
susceptibility patterns. The importance of national programs
to support and monitor the implementation of these guidelines
has been demonstrated [16, 38]. Local stakeholders, including
surgeons, anesthetists, specialty pharmacists, microbiologists,
and infection control specialists, should develop local guide-
lines or protocols [60]. These local guidelines/protocols
should be flexible to allow for clinical judgment and easy
adherence. Local guidelines involve each specific situation,
making monitoring and management easier.
Debate regarding the efficacy of postoperative meningitis
Postoperative meningitis seldom occurs, but it is more likely
to cause death or lasting disability than extradural infections.
In one study, AP was not found to be a risk factor in post-
craniotomy meningitis [20]. Korinek [61] collected 6,243
consecutive craniotomies from 10 hospitals; the meningitis
infection rate was 1.63 % in patients without AP and 1.50 % in
those with prophylaxis. It seems that AP does not prevent
meningitis and may tend to select prophylaxis-resistant mi-
croorganisms. Two studies found that Gram-negative bacteria
were the most common etiologic agents to cause postoperative
meningitis, which is distinct from the extradural infections
that are caused by Gram-positive bacteria. However, both
Alternative
[71] Cefazolin Vancomycin
[50] Cefazolin Clindamycin or vancomycin
[72] Clean: cefazolin, clean– Flucloxacillin, glycopeptide (only with
contaminated: second- frequent occurrence of wound
generation cephalosporins infections by MRSA)
[73] Cefazolin+clindamycin (if –
paranasal sinuses are
involved)
[33] Cover expected pathogens, –
narrow spectrum, less
expensive
[74] Cefazolin Vancomycin or clindamycin
[35] First-generation cephalosporins, –
aminopenicillin
412
studies were retrospective and may include bias. Barker sub-
sequently conducted a meta-analysis [62] and reviewed six
prospective randomized trials [12, 20, 26, 27, 63, 64], which
enrolled 1,729 craniotomy patients. The pooled odds ratio for
meningitis with antibiotic treatment was 0.43 (95 % confi-
dence interval, 0.20–0.92; 0.03). Prophylactic antibiotics re-
duced the rate of postoperative meningitis by approximately
one half, a statistically and clinically significant benefit. This
is a robust result because the conclusion was drawn from the
highest level of evidence. We should note that these trials were
performed more than 20 years ago, and the validity of data
from varying periods adds doubt to the current relevance of
the conclusions. The different etiologies, clinical manifesta-
tions, and prognoses of intradural and extradural infections
may indicate that the debate is likely to continue.
S. aureus surveillance and decolonization therapy
In some institutions, an increase in MRSA SSI has led to
investigations into the methods for the preoperative eradica-
tion of MRSA, particularly with intranasal mupirocin. A large
prospective crossover study evaluated the effects of MRSA
screening for surgical patients at one facility in Switzerland
[65]. The intervention group underwent early detection and
isolation of MRSA, adjustment of perioperative AP, and top-
ical decolonization with a nasal mupirocin ointment and
chlorhexidine body washes. This strategy did not reduce
nosocomial MRSA infections in the surgical department. A
Netherlands trial obtained a positive result when monitoring
S. aureus [66]. A randomized, double-blind, placebo-
controlled multicenter study evaluated the incidence of
hospital-acquired infection. They used mupirocin for the de-
colonization of S. aureus after rapid identification and a daily
skin shower with chlorhexidine. The cumulative incidence of
healthcare-associated S. aureus infection was 17 out of 504
(3.4 %) in the mupirocin–chlorhexidine group and 32 out of
413 (7.7 %) in the placebo group (RR, 0.42 [95 % CI, 0.23–
0.75]). The rates of deep SSI were 0.9 % (4 out of 441
patients) and 4.4 % (16 out of 367 patients) in the control
and placebo groups, respectively. The number of S. aureus
SSIs can be reduced by screening and decolonizing nasal
carriers of S. aureus upon admission.
The cost-effectiveness of universally screening patients for
S. aureus remains questionable. Considerations include the
additional time needed for infection control and laboratory
specialists, as well as the materials needed for surveillance and
laboratory analysis. It is unknown how these considerations
compare with the potential costs associated with MRSA in-
fection and the length of stay.
Mupirocin is most often used to decolonize S. aureus.
Although most studies conclude that intranasal mupirocin is
safe and efficient, mupirocin-resistant S. aureus has been
identified [51, 67]. The appearance of resistant organisms
Neurosurg Rev (2014) 37:407–414
raises concern for the future widespread routine use of this
agent. The use of decolonization therapy may be used as an
adjunctive measure to control the spread of MRSA in con-
junction with vigilant surveillance of susceptibility testing
[68].
Although AP can reduce the rate of SSI, it must be used
properly to prevent adverse reactions. From this review, we
are more aware than ever that antibiotics involve both risks
and benefits. We should use AP more carefully and continue
to update our knowledge. More clinical and basic studies are
needed to improve our AP strategies in the new era.
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Comments
Marian Christoph Neidert and Oliver Bozinov, Zurich, Switzerland
In times of growing antibiotic resistance and emerging public health
concerns related to nosocomial infections, Dr. Liu and colleagues submit
an interesting review article on antibiotic prophylaxis (AP) in craniotomy.
This article is a well-structured overview on AP in neurosurgery, not only
including current evidence but also a historic vignette on this topic. The
individual evaluation of antibiotics that are frequently used for prophy-
laxis is both informative and based on a thorough review of the literature.
The authors stress some key points of AP: One is that prophylactic
antibiotics are given to prevent infections by skin flora, not the causative
organisms. Thus, an agent that is useful for treatment of a certain infection
(e.g., meningitis) is not necessarily chosen for its prevention.
Another major merit of this article is that raises awareness in the
neurosurgical society for an ever more important topic that might have
been neglected in the past. In our opinion, the authors correctly state that
the adherence of surgeons to established guidelines regarding AP is
suboptimal. Surgical side infections, especially in neurosurgery, are as-
sociated with significant mortality and morbidity. Moreover, the financial
burden linked to increased treatment costs is serious. Efforts in research
and education on AP and the prevention of surgical site infections are
wise investments. The authors should be congratulated for choosing this
topic for a review article.