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February 2011
Patient Care and Science
EIN Update: Antimicrobial Prophylaxis and Neurosurgical Procedures

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds the EIN. The reader assumes all risks in using this information.

In several discussions during the past two years, EIN members have raised questions about cerebrospinal fluid shunts, extraventricular drains, and the use of antimicrobial prophylaxis for infection control in these procedures. The responses have highlighted a range in practice in these areas and a need for additional data.

In April of 2009, an EIN member in Ohio asked about current practices for antibiotic prophylaxis, including antibiotic choice and duration, for extraventricular drains. “Our surgeons prefer to continue antibiotics until the drains are out,” the member wrote. “Each has a particular combo that makes more or less sense.”

But “given scant data and the fact that our recommendation to discontinue the antibiotics within 24 hours of surgery is backed up by 15-year-old guidelines but no clear statement in regards to neurosurgical procedures,” the member asked for input from other EIN members.

A New Jersey member, one of only two respondents, wrote that “our pediatric neurosurgeons use prophylaxis for as long as the drain is in place,” with oxacillin being used unless the patient is known to have methicillin-resistant Staphylococcus aureus (MRSA) or is penicillin allergic, in which case vancomycin is used. “We were not involved in the development of their care plan,” the respondent noted.

In June of 2010, an Ohio member asked for “input on the choice of antibiotic for pre-surgical prophylaxis for VP [ventriculo-peritoneal] shunt placement in both the neonatal age group and beyond.”

Draft therapeutic guidelines, available online, include antibiotic prophylaxis recommendations for neurosurgery procedures, a respondent in Georgia wrote.  The American Society of Health-System Pharmacists (ASHP), IDSA, the Surgical Infection Society, and the Society for Healthcare Epidemiology of America are collaborating on these guidelines, which should be completed later this year. For more information, see the ASHP website.

In January of 2011, an EIN member in Florida described a request from neurosurgery colleagues “who want to use one dose of intraventricular vancomycin and gentamicin at time of VP shunt placement. I have used these two agents on rare occasions as a therapeutic alternative,” the member wrote, “but not as a prophylactic agent. Any experience with intraventricular antibiotics prophylaxis?”

Although practiced by some neurosurgeons, a Texas respondent replied that this was not standard therapy and not an approved use of the medication by the Food and Drug Administration.

In another discussion in January of 2009, an EIN member in Georgia asked for comments on infection control practices for VP shunt placement in infants and children, including pre-operative bathing, soaking portions of shunts in antibacterial solution, and irrigation, among other related topics. A respondent in Iowa replied that in her facility, bathing was not used in these cases, and shunts were irrigated with bacitracin. “Our surgeons use antibiotic impregnated catheters,” the member wrote. “Some staff inject gentamicin into the reservoir after it is placed.”

As in the other discussions, however, the lack of other respondents suggests a need for more supporting data for this important clinical topic.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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