Discontinuation of Postoperative Prophylactic Antibiotics for Endoscopic Endonasal Skull Base Surgery

Yosef Dastagirzada; Carolina Benjamin; Julia Bevilacqua; Jason Gurewitz; Chandra Sen; John G. Golfinos; Dimitris Placantonakis; Jafar J. Jafar; Seth Lieberman; Rich Lebowitz; Ariane Lewis; Donato Pacione

doi:10.1055/a-1771-0372

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2023; 84(02): 157-163
DOI: 10.1055/a-1771-0372

Original Article

Discontinuation of Postoperative Prophylactic Antibiotics for Endoscopic Endonasal Skull Base Surgery

Authors

Yosef Dastagirzada^*

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Carolina Benjamin^*

²Department of Neurosurgery, University of Miami, Miami, Florida, United States
Julia Bevilacqua

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Jason Gurewitz

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Chandra Sen

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
John G. Golfinos

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Dimitris Placantonakis

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Jafar J. Jafar

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States
Seth Lieberman

³Department of Otolaryngology, NYU Langone Health, New York, New York, United States
Rich Lebowitz

³Department of Otolaryngology, NYU Langone Health, New York, New York, United States
Ariane Lewis

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States

⁴Department of Neurology, NYU Langone Health, New York, New York, United States
Donato Pacione

¹Department of Neurosurgery, NYU Langone Health, New York, New York, United States

Abstract

Background Postoperative prophylactic antibiotic usage for endoscopic skull base surgery varies based on the institution as evidence-based guidelines are lacking. The purpose of this study is to determine whether discontinuing postoperative prophylactic antibiotics in endoscopic endonasal cases led to a difference in central nervous system (CNS) infections, multi-drug resistant organism (MDRO) infections, or other postoperative infections.

Methods This quality improvement study compared outcomes between a retrospective cohort (from September 2013 to March 2019) and a prospective cohort (April 2019 to June 2019) after adopting a protocol to discontinue prophylactic postoperative antibiotics in patients who underwent endoscopic endonasal approaches (EEAs). Our primary end points of the study included the presence of postoperative CNS infection, Clostridium difficile (C. diff), and MDRO infections.

Results A total of 388 patients were analyzed, 313 in the pre-protocol group and 75 in the post-protocol group. There were similar rates of intraoperative cerebrospinal fluid leak (56.9 vs. 61.3%, p = 0.946). There was a statistically significant decrease in the proportion of patients receiving IV antibiotics during their postoperative course (p = 0.001) and those discharged on antibiotics (p = 0.001). There was no significant increase in the rate of CNS infections in the post-protocol group despite the discontinuation of postoperative antibiotics (3.5 vs. 2.7%, p = 0.714). There was no statistically significant difference in postoperative C. diff (0 vs. 0%, p = 0.488) or development of MDRO infections (0.3 vs 0%, p = 0.624).

Conclusion Discontinuation of postoperative antibiotics after EEA at our institution did not change the frequency of CNS infections. It appears that discontinuation of antibiotics after EEA is safe.

Keywords

endoscopic endonasal surgery - endoscopic endonasal approach - transsphenoidal - antibiotics - prophylaxis - pituitary

Full Text

References

References
1 Kono Y, Prevedello DM, Snyderman CH. et al. One thousand endoscopic skull base surgical procedures demystifying the infection potential: incidence and description of postoperative meningitis and brain abscesses. Infect Control Hosp Epidemiol 2011; 32 (01) 77-83
2 Milanese L, Zoli M, Sollini G. et al. Antibiotic prophylaxis in endoscopic endonasal pituitary and skull base surgery. World Neurosurg 2017; 106: 912-918
3 Saleh AM, Torres KM, Murad MH, Erwin PJ, Driscoll CL. Prophylactic perioperative antibiotic use in endoscopic sinus surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 2012; 146 (04) 533-538
4 Rosen SA, Getz AE, Kingdom T, Youssef AS, Ramakrishnan VR. Systematic review of the effectiveness of perioperative prophylactic antibiotics for skull base surgeries. Am J Rhinol Allergy 2016; 30 (02) e10-e16
5 Johans SJ, Burkett DJ, Swong KN, Patel CR, Germanwala AV. Antibiotic prophylaxis and infection prevention for endoscopic endonasal skull base surgery: our protocol, results, and review of the literature. J Clin Neurosci 2018; 47: 249-253
6 Patel S, Thompson D, Innocent S, Narbad V, Selway R, Barkas K. Risk factors for surgical site infections in neurosurgery. Ann R Coll Surg Engl 2019; 101 (03) 220-225
7 Chiang H-Y, Kamath AS, Pottinger JM. et al. Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy. J Neurosurg 2014; 120 (02) 509-521
8 Little AS, White WL. Prophylactic antibiotic trends in transsphenoidal surgery for pituitary lesions. Pituitary 2011; 14 (02) 99-104
9 Dellit TH, Chan JD, Fulton C. et al. Reduction in Clostridium difficile infections among neurosurgical patients associated with discontinuation of antimicrobial prophylaxis for the duration of external ventricular drain placement. Infect Control Hosp Epidemiol 2014; 35 (05) 589-590
10 Castelnuovo P, Dallan I, Battaglia P, Bignami M. Endoscopic endonasal skull base surgery: past, present and future. Eur Arch Otorhinolaryngol 2010; 267 (05) 649-663
11 Gransden WR, Wickstead M, Eykyn SJ. Meningitis after trans-sphenoidal excision of pituitary tumours. J Laryngol Otol 1988; 102 (01) 33-36
12 Sundaresan N, Shah JP. Craniofacial resection for anterior skull base tumors. Head Neck Surg 1988; 10 (04) 219-224
13 Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal surgery. Case reports and analysis of risk factors. Arch Otolaryngol Head Neck Surg 1986; 112 (03) 329-332
14 Carrau RL, Snyderman C, Janecka IP, Sekhar L, Sen C, D'Amico F. Antibiotic prophylaxis in cranial base surgery. Head Neck 1991; 13 (04) 311-317
15 Somma T, Maraolo AE, Esposito F. et al. Efficacy of ultra-short single agent regimen antibiotic chemo-prophylaxis in reducing the risk of meningitis in patients undergoing endoscopic endonasal transsphenoidal surgery. Clin Neurol Neurosurg 2015; 139: 206-209
16 Lewis A, Sen R, Hill TC. et al. Antibiotic prophylaxis for subdural and subgaleal drains. J Neurosurg 2017; 126 (03) 908-912
17 Lewis A, Lin J, James H, Hill TC, Sen R, Pacione D. Discontinuation of postoperative prophylactic antibiotics after noninstrumented spinal surgery: results of a quality improvement project. Neurohospitalist 2018; 8 (03) 129-134
18 Horowitz G, Fliss DM, Margalit N, Wasserzug O, Gil Z. Association between cerebrospinal fluid leak and meningitis after skull base surgery. Otolaryngol Head Neck Surg 2011; 145 (04) 689-693
19 Makwana M, Taylor PN, Stew BT, Shone G, Hayhurst C. Smoking and obesity are risk factors for thirty-day readmissions following skull base surgery. J Neurol Surg B Skull Base 2020; 81 (02) 206-212
20 Kong L, Liu Z, Meng F, Shen Y. Smoking and risk of surgical site infection after spinal surgery: a systematic review and meta-analysis. Surg Infect (Larchmt) 2017; 18 (02) 206-214
21 Dasenbrock HH, Liu KX, Chavakula V. et al. Body habitus, serum albumin, and the outcomes after craniotomy for tumor: a National Surgical Quality Improvement Program analysis. J Neurosurg 2017; 126 (03) 677-689
22 Wang J, Cai C, Wang S. Merocel versus Nasopore for nasal packing: a meta-analysis of randomized controlled trials. PLoS One 2014; 9 (04) e93959