From the Guidelines
The recommended antibiotic prophylaxis regimen for patients undergoing External Ventricular Drain (EVD) placement is a single preoperative dose of cefazolin, as emphasized by the most recent and highest quality study 1.
Key Considerations
- The use of antimicrobials such as cefazolin is necessary to reduce the rate of surgical site infections and central nervous system infections in patients with EVDs 1.
- Perioperative chlorhexidine shampoo and hair clipping, with special care to avoid causing skin abrasions, should also be implemented 1.
- The introduction of an EVD care bundle that includes a standardized technique of hand washing for aseptic CSF sampling, the use of surgical theater-standard scrubs and preparations, and cleaning the EVD access ports while wearing a mask and gloves can significantly decrease the rate of infection 1.
Antibiotic Prophylaxis Regimen
- A single preoperative dose of cefazolin 2g IV (or 3g for patients weighing >120kg) is recommended, administered within 60 minutes before surgical incision.
- For patients with beta-lactam allergies, alternatives include clindamycin 900mg IV or vancomycin 15mg/kg IV (started 60-120 minutes before incision due to longer infusion time).
Rationale
- The rationale for prophylaxis is to prevent surgical site infections and ventriculitis/meningitis by achieving adequate tissue concentrations of antibiotics at the time of potential bacterial contamination during the procedure.
- EVDs penetrate the blood-brain barrier, creating a direct pathway for pathogens to enter the central nervous system, making appropriate prophylaxis crucial.
Institutional Considerations
- Institutions may have specific protocols based on local resistance patterns, so it's advisable to consult local guidelines when available.
- The use of silver-coated and minocycline- and rifampin-impregnated catheters has proven to be cost-effective in significantly reducing the rate of infection in EVDs 1.
From the Research
Antibiotic Prophylaxis Regimens for EVD Placement
- The recommended antibiotic prophylaxis regimen for patients undergoing External Ventricular Drain (EVD) placement is not explicitly stated in the provided studies, but the duration of antibiotic prophylaxis is discussed in several studies 2, 3.
- A study published in 2020 found that limiting antibiotic prophylaxis to a single preoperative dose did not increase the risk of drain-related infections (DRIs) and reduced antibiotic exposure 2.
- Another study published in 2022 found that discontinuing extended postprocedural antibiotics was associated with a significant decrease in the incidence of Clostridioides difficile infection without a concomitant change in postprocedural infections or EVD-associated infection 3.
Risk Factors for EVD Infections
- Several risk factors for EVD infections are identified in the studies, including prior brain surgery associated with cerebrospinal fluid (CSF) diversion, CSF leak around the catheter, and insertion site dehiscence 4.
- The duration of EVD use >7 days was not associated with an increased risk of infection in one study 4, while another study found that longer duration of catheterization was associated with an increased risk of infection 5.
EVD Placement and Infection Rates
- The overall infection rate for EVD placement was found to be 1.86% in one study 6 and 2.2% in another study 4.
- The use of a standardized EVD placement protocol was associated with a low risk of ERI regardless of the duration of catheter utilization 6.
- The infection rate did not correlate with known risk factors such as diabetes and steroids, operation start time, or duration of surgery, although intraoperative antibiotic prophylaxis seemed to reduce the infection rate 5.