From the Guidelines
The standard of care for a patient with a Staphylococcus aureus positive swab post craniectomy requires prompt antibiotic therapy based on susceptibility testing, with a recommended treatment duration of 4-6 weeks for uncomplicated infections to 8-12 weeks for more complex cases. For methicillin-sensitive S. aureus (MSSA), intravenous nafcillin or oxacillin at 2g every 4 hours is recommended 1. For methicillin-resistant S. aureus (MRSA), intravenous vancomycin at 15-20 mg/kg every 8-12 hours (adjusted for renal function and to achieve trough levels of 15-20 μg/mL) is the preferred treatment, as indicated by the guidelines for the treatment of MRSA infections 1. Some key points to consider in the management of these infections include:
- Identification, elimination, and/or debridement of the primary source and other sites of infection when possible 1
- Follow-up blood cultures 2–4 days after initial positive cultures and as needed thereafter to document clearance of bacteremia 1
- Trough monitoring to achieve target concentrations of 15–20 lg/mL in patients with serious MRSA infections 1
- Consideration of alternative treatments, such as daptomycin or linezolid, in vancomycin-intolerant patients Surgical debridement is often necessary alongside antibiotics to remove infected tissue and hardware. Close monitoring for neurological symptoms, fever, and wound changes is essential. This aggressive approach is necessary because S. aureus infections following cranial surgery can lead to serious complications including meningitis, brain abscess, osteomyelitis of the skull, or systemic infection, all of which carry significant morbidity and mortality risks. The use of antibiotic prophylaxis in neurosurgery, such as cefazolin, is also an important consideration in preventing post-surgical infections 1.
From the FDA Drug Label
Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci Vancomycin Hydrochloride for Injection, USP has been reported to be effective alone or in combination with an aminoglycoside for endocarditis caused by S. viridans or S. bovis. When staphylococcal infections are localized and purulent, antibiotics are used as adjuncts to appropriate surgical measures
The standard of care for a patient with a Staphylococcus aureus positive swab post craniectomy may involve the use of vancomycin as it is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant staphylococci.
- Key points:
- Vancomycin is effective against Staphylococcus aureus, including methicillin-resistant strains.
- The use of vancomycin should be based on susceptibility data and local epidemiology.
- Surgical measures are also important in the treatment of localized and purulent staphylococcal infections.
- The choice of antibiotic should be guided by culture and susceptibility results, as well as clinical judgment 2.
- Alternative options:
- Linezolid may also be effective against Staphylococcus aureus, including methicillin-resistant strains, as shown in the susceptibility data 3.
From the Research
Standard of Care for Staphylococcus aureus Positive Swab Post Craniectomy
The standard of care for a patient with a Staphylococcus aureus positive swab post craniectomy involves immediate recognition and treatment of the infection. According to 4, postoperative infection after cranial surgery is a serious complication that requires prompt attention.
Treatment Options
- Antibiotic therapy is a crucial component of treatment, with the choice of antibiotic depending on the susceptibility of the organism 5.
- In cases of methicillin-resistant Staphylococcus aureus (MRSA) infection, linezolid may be considered as a second-line antibiotic therapy due to its good central nervous system (CNS) penetration 6.
- Vancomycin is also effective against MRSA infection, but its penetration into the CNS is poor 6.
- Empirical treatment of surgical infections after craniotomy should include a glycopeptide such as vancomycin and a beta-lactam with coverage against non-fermenting gram-negative bacilli 7.
Prevention of Surgical Site Infections
- The use of a peri-operative bundle, including peri-operative vancomycin, a barrier dressing, and de-colonization of the surgical incision using topical chlorhexidine, can reduce the rate of surgical site infections (SSI) and the need for re-do cranioplasties 8.
- Factors associated with SSI, such as peri-operative vancomycin, should be carefully managed to minimize the risk of infection.
Key Considerations
- The most common aetiology of surgical infections after craniotomy is staphylococci, mainly S. aureus, with a significant proportion being methicillin-resistant 7.
- The rate of MRSA colonization in cranioplasty patients is higher than the average seen on ICU admission screening 8.
- Prompt recognition and treatment of postoperative infection after cranial surgery are essential to prevent serious complications and improve patient outcomes 4.