Cefazolin versus vancomycin for neurosurgical operative prophylaxis – A single institution retrospective cohort study

https://doi.org/10.1016/j.clineuro.2019.05.017Get rights and content

Highlights

  • Cefazolin and vancomycin are comparable prophylaxes for neurosurgical infection.

  • Neurosurgical infection after cefazolin prophylaxis often contains S. aureus.

  • Surgery within the previous year was associated with a higher risk of infection.

Abstract

Objectives

Cefazolin and vancomycin are common choices for neurosurgical antimicrobial prophylaxis. Cefazolin is typically first-line due to its lower toxicity profile and specificity for gram-positives such as skin commensals, while vancomycin is often reserved for patients with cephalosporin or penicillin allergies. However, one randomized clinical trial demonstrated superiority of vancomycin for cerebrospinal fluid (CSF) shunt insertions at a hospital with a high prevalence of methicillin-resistance Staphylococcus aureus (MRSA). We aimed to evaluate the association of prophylaxis choice and incidence of surgical site infection (SSI) at our own institution.

Patients and methods

This was a retrospective cohort study of patients who underwent a neurosurgical operation from January 2013 to April 2016 at one particular hospital belonging to our institution. We included patients who received either only cefazolin or only vancomycin as their pre-incisional prophylaxis. Vancomycin was substituted for cefazolin in patients with known penicillin or cephalosporin allergy. Procedures requiring multiple attending surgeons were excluded. We defined a SSI as a confirmed culture isolated from the wound, implant (if pertinent), or CSF (if pertinent) within a year of surgery. Multivariable logistic regression was performed with consideration of antibiotic, operation performed, wound class, and procedure length.

Results

A total of 859 operations met study criteria; 664 patients received Cefazolin, and 195 received Vancomycin. We identified 22 SSIs, with 14 in the cefazolin (2.2%) and 8 in the vancomycin (4.1%) group. Upon logistic regression, there was no significant association of vancomycin substitution with incidence of SSIs between the two groups (odds ratio, 1.59; 95% CI, 0.42–6.00, p = .49). In the cefazolin group, 8/14 cultures were positive for S. aureus compared to 1/8 of the vancomycin group.

Conclusions

There was no significant difference in neurosurgical site infection incidence when vancomycin prophylaxis was substituted for cefazolin. S. aureus was isolated from patients who received cefazolin at a higher rate although this was not statistically significant. At our institution, S. aureus makes up 36% of isolated organisms from inpatient and intensive care units. Institutions should consider their own investigations into local antibiograms, SSI rates, and choice of prophylaxis.

Introduction

Healthcare-associated infections can be costly to hospitals and dangerous to patients, especially when related to surgery [1]. Surgical site infections (SSI) for patients undergoing neurosurgery are the costliest among the surgical specialties, as each SSI was estimated to cost $23,755 in 2010 [2]. SSI incidence rates in neurosurgery vary by procedure and location but are estimated occur at a rate of 1–10% [[3], [4], [5], [6], [7], [8]]. Approximately 14 million neurosurgical procedures were performed in 2017, which would equate to anywhere from 140,000 to 1.4 million neurosurgical patients developing potentially dangerous SSIs [9,10].

A number of different variables have been identified as risk factors for development of SSI in neurosurgical procedures such as surgical duration, wound contamination, and CSF leak [4,5,11]. Although past studies of neurosurgical pre-incisional antibiotic prophylaxis have demonstrated mixed efficacy, general expert consensus, including The United States Center for Disease Control and Prevention (CDC) guidelines for global reduction of SSIs, supports antibiotic prophylaxis [4,[12], [13], [14], [15], [16]].

Recommended prophylactic agents for neurosurgical procedures are cefazolin, gentamicin, and vancomycin [17]. Cefazolin is considered to be a reasonable first-line option that covers skin commensals and other organisms frequently implicated in neurosurgical SSI [18]. One Italian study of cerebrospinal fluid (CSF) shunt insertions determined that vancomycin prophylaxis reduced shunt infection rate and mortality compared to cefazolin [19]. Another study from that hospital had previously reported that the majority of infections in neurosurgical patients were caused by Staphylococcus aureus, with 39% of those being methicillin-resistant [20]. In this study, we aimed to determine if patients who underwent vancomycin prophylaxis instead of cefazolin prophylaxis experienced a significantly different incidence of SSIs following general neurosurgical procedures.

Section snippets

Patients and methods

In this retrospective cohort study, we reviewed the records of patients who underwent a neurosurgical operation between January of 2013 and April of 2016 in one particular hospital. In mid-April 2016, surgeries were relocated to a newer hospital. Patients were included if they were not incarcerated and underwent a procedure by one of the three attending neurosurgeons who were continuously employed during the study period. We excluded cases in which the prophylactic antibiotic administered was

Results

A total of 859 operations met the study criteria; 664 patients received cefazolin, and 195 received vancomycin. Patient demographic data and other descriptive statistics can be found in Table 1. Using the standard SSI definition, there were 23 (3.4%) SSIs, with 18 (2.7%) in the cefazolin group and 5 (2.6%) in the vancomycin group. Of these SSIs, 22 had a confirmed culture or histological diagnosis, and 4 were clinically diagnosed. Using the study SSI definition, there were 22 (2.6%), with 14

Discussion

Using both the standard SSI definition and our modified definition, which expands the analysis to one year after the operation and requires a histologically-confirmed or culture-confirmed diagnosis, our results demonstrated no difference in incidence of SSIs between patients who received solely cefazolin compared to vancomycin for neurosurgical prophylaxis. The incidence rate of SSIs (2.6–3.4%) at our institution was consistent with previously reported statistics [[3], [4], [5], [6], [7], [8]].

Conclusion

Choice of cefazolin versus vancomycin prophylaxis was not significantly associated with a difference in rates of SSI development. Previous incision at or near the surgical site within the previous year was associated with increased risk of developing a wound infection. Although our study did not demonstrate statistical significance, patients who receive cefazolin prophylaxis may be more likely to have S. aureus isolated from wound cultures. Institutions should carefully review antibiogram

Conflicts of interest

The authors report that there are no conflicts of interest or financial relationships to report.

Acknowledgements

None.

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