Surgical prophylaxis for neurosurgery
Consider the principles for appropriate prescribing of surgical antibiotic prophylaxis (see Principles for appropriate prescribing of surgical antibiotic prophylaxis). See Neurosurgery procedures and their requirement for surgical antibiotic prophylaxis for the recommendations for surgical prophylaxis for neurosurgery.
The benefit of routine antibiotic prophylaxis for the insertion of external ventricular drains has not been demonstrated in clinical trials. Despite this, a single dose of prophylaxis is recommended in these guidelines, in line with consensus guidelines from the Neurocritical Care Society, because postoperative infection would have serious consequences1.
There is no evidence that antibiotic prophylaxis for basilar skull fracture reduces the incidence of meningitis, mortality or the need for surgical correction. Therefore, antibiotic prophylaxis is not indicated for patients with cerebrospinal fluid (CSF) leakage following trauma. However, patients with CSF leak should be vaccinated against Streptococcus pneumoniae to protect against the development of pneumococcal meningitis. See the Australian Immunisation Handbook for further information.
For neurosurgical spinal procedures, see Surgical prophylaxis for spinal surgery.
For a printable summary table of the indications and regimens for surgical antibiotic prophylaxis, see here.
|
Procedures |
Is surgical antibiotic prophylaxis indicated? |
|---|---|
|
intracranial shunt insertion [NB1] pressure monitor insertion craniotomy microsurgery procedures involving insertion of prosthetic material re-exploration procedures external ventricular drain insertion |
YES |
Note:
NB1: Patients scheduled for insertion of an intracranial shunt should be vaccinated against Streptococcus pneumoniae, ideally before the procedure, to protect against the development of pneumococcal meningitis. See the Australian Immunisation Handbook for further information. | |
For prophylaxis for neurosurgery procedures, use:
cefazolin 2 g (child: 30 mg/kg up to 2 g) intravenously, within the 60 minutes before surgical incision; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed. surgical prophylaxis, neurosurgery cefazolin
For patients colonised or infected with methicillin-resistant Staphylococcus aureus (MRSA), or at increased risk of being colonised or infected with MRSA (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to cefazolin:
vancomycin (adult and child) 15 mg/kg up to 2 g intravenously, started within the 120 minutes before surgical incision (recommended rate 10 mg/minute)2; intraoperative redosing may be required (see here ). Do not give additional doses once the procedure is completed. surgical prophylaxis, neurosurgery vancomycin
For patients with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, use cefazolin, with or without vancomycin, as above. See also Surgical antibiotic prophylaxis for patients with a penicillin or cephalosporin allergy.
For patients with immediate severe or delayed severe hypersensitivity to penicillins, use vancomycin as monotherapy (see dosage above).
Ventricular drains that remain in situ do not justify extending the duration of antibiotic prophylaxis postoperatively. Extended prophylaxis is associated with an increased risk of adverse effects, including subsequent infection with resistant pathogens and Clostridioides difficile.
The rate of shunt infection is reduced when the shunt is impregnated with an antibiotic (clindamycin or rifampicin), but data are lacking on the risk of selecting resistant organisms.