What are the Indian guidelines for antibiotic prophylaxis in neurosurgical procedures?

Indian Guidelines for Antibiotic Prophylaxis in Neurosurgical Procedures

Based on the available evidence, antibiotic prophylaxis in neurosurgical procedures should be limited to a single preoperative dose, with possible extension to 24 hours, exceptionally 48 hours, and never beyond. 1

General Principles

• Antibiotic prophylaxis should be brief, limited to the operative period, sometimes 24 hours, exceptionally 48 hours, and never beyond to prevent development of resistant organisms 1
• A single preoperative injection has proven effective for many interventions, and prescription beyond 48 hours is prohibited in all cases 1
• Effective tissue concentrations must be maintained throughout the procedure, with coverage of prolonged surgery achieved either by using an antibiotic with a long half-life or with intraoperative reinjection 1
• The presence of drainage does not justify extending prophylaxis beyond the recommended duration 1

Specific Recommendations for Neurosurgical Procedures

CSF Shunt Procedures

• For CSF shunt: Cefazolin 2g IV slow (single dose, reinject 1g if duration >4h) 1
• For allergy: Vancomycin 30 mg/kg over 120 min (single dose) 1
• For external CSF shunt: No antibiotic prophylaxis recommended 1

Craniotomy

• For craniotomy: Cefazolin 2g IV slow (single dose, reinject 1g if duration >4h) 1
• For allergy: Vancomycin 30 mg/kg over 120 min (single dose) 1

Transsphenoidal and Trans-labyrinthine Approaches

• For neurosurgery via transsphenoidal routes and trans-labyrinthine approaches: Cefazolin 2g IV slow (single dose, reinject 1g if duration >4h) 1
• For allergy: Vancomycin 30 mg/kg over 120 min (single dose) 1

Spine Surgery with Implantation

• For spine surgery with implantation of prosthetic material: Cefazolin 2g IV slow (single dose, reinject 1g if duration >4h) 1
• For allergy: Vancomycin 30 mg/kg over 120 min (single dose) 1

Cranio-cerebral Wounds

• For cranio-cerebral wounds: Aminopenicillin + beta-lactamase inhibitor 2g IV slow (2g every 8 hours, maximum 48h) 1
• For allergy: Vancomycin 30 mg/kg over 120 min (30 mg/kg/day, maximum 48h) 1

Skull Base Fracture with Rhinorrhea

• For fracture of skull base with rhinorrhea: No antibiotic prophylaxis recommended 1

Special Considerations

• Without antibiotic prophylaxis in neurosurgery, the risk of infection is 1-5% for craniotomy with and without implantation of foreign material 1
• The risk increases to approximately 10% when a cerebrospinal fluid shunt is present 1
• Target bacteria include Enterobacteriaceae (especially after craniotomies), staphylococci (S. aureus and S. epidermidis), and anaerobic bacteria (especially after cranio-cerebral wounds) 1
• Vancomycin should be reserved for specific indications: allergy to beta-lactams, suspected or proven colonization by methicillin-resistant staphylococcus, reoperation in a patient hospitalized in a unit with MRSA ecology, or previous antibiotic therapy 1
• Vancomycin injection should last 120 minutes and must end at the latest at the beginning of the intervention, ideally 30 minutes before 1

Timing of Administration

• The first dose of antibiotic prophylaxis should be administered within 60 minutes before surgical incision, with a goal of 30 minutes before incision to ensure adequate tissue concentration at the time of surgery 2
• Complete infusion of the antibiotic should occur before the surgical incision 3

Common Pitfalls and Caveats

• Prolonging antibiotic prophylaxis beyond the recommended duration increases the risk of antibiotic resistance without providing additional benefit 1, 2
• Failure to administer the initial dose before incision significantly reduces the effectiveness of prophylaxis 2, 3
• The prescription of antibiotic prophylaxis should be an integral part of the preoperative consultation, taking into account the planned intervention, patient history, and ecology of the surgical ward 1