From the Guidelines
Patients undergoing craniectomy should receive prophylactic antibiotics, with cefazolin being the standard choice, at a dose of 2g IV slow, as a single dose, with re-injection of 1g if the duration of surgery exceeds 4 hours. This recommendation is based on the most recent and highest quality study available, which provides guidelines for antibiotic prophylaxis in surgery and interventional medicine, including neurosurgery 1. The study highlights the importance of antibiotic prophylaxis in reducing the risk of infection in neurosurgical procedures, including craniotomy with and without implantation of foreign material.
Key Considerations
- The recommended dose of cefazolin is 2g IV slow, with re-injection of 1g if the duration of surgery exceeds 4 hours 1.
- For patients with allergies to beta-lactams, vancomycin is recommended at a dose of 30 mg/kg/120 min, as a single dose 1.
- The use of antibiotic prophylaxis is crucial in reducing the risk of infection, which can lead to serious complications, including meningitis, cerebral abscess, bone flap infection, and increased mortality.
Postoperative Antibiotic Protocols
- The duration of postoperative antibiotic prophylaxis is typically limited to 24-48 hours after surgery, as extended courses do not reduce infection rates and may promote antibiotic resistance.
- For patients with contaminated wounds or those at high risk for infection, antibiotic coverage may be broadened to include gram-negative coverage with agents like ceftriaxone or piperacillin-tazobactam.
- The rationale for perioperative antibiotics is to achieve adequate tissue concentrations during the period of potential bacterial contamination, as surgical site infections following cranial procedures can lead to serious complications.
From the FDA Drug Label
To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. For lengthy operative procedures (e.g., 2 hours or more), 500 mg to 1 gram IV or IM during surgery (administration modified depending on the duration of the operative procedure). 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively
The postoperative antibiotic protocol for a craniectomy using cefazolin is:
- 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively 2. Key points:
- The protocol may vary depending on the duration of the operative procedure and the patient's renal function.
- In some cases, such as open-heart surgery and prosthetic arthroplasty, the prophylactic administration of cefazolin may be continued for 3 to 5 days following the completion of surgery.
From the Research
Postoperative Antibiotic Protocols for Craniectomy
- The choice of antibiotic prophylaxis after craniotomy is often based on the antibiotic's resistance profile and drug-induced complications 3.
- A decision tree model comparing cefazolin, vancomycin, or their combination found that cefazolin was the preferred strategy in most cases, with a slightly greater expected survival compared to other strategies 3.
- Topical vancomycin has been shown to be safe and effective in reducing surgical site infections after craniotomy, with a lower incidence of infections compared to standard antibiotic prophylaxis alone 4.
- A Bayesian network meta-analysis found that penicillins and cephalosporins are the best choice for antibiotic prophylaxis in head and neck cancer surgery, with no significant difference between short and long course prophylaxis 5.
- A retrospective multi-institution analysis found that prolonging ampicillin/sulbactam beyond the day of surgery may have a protective effect against surgical site infections, while prolonging clindamycin was associated with a higher odds of infection 6.
Antibiotic-Related Complications
- Cefepime-induced neurotoxicity is a potential complication of antibiotic prophylaxis, with symptoms including depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma 7.
- Risk factors for cefepime-induced neurotoxicity include renal dysfunction, excessive dosing, preexisting brain injury, and elevated serum cefepime concentrations 7.
- Symptom improvement and survival are possible with cefepime discontinuation, antiepileptic administration, or hemodialysis 7.
Recommended Antibiotics
- Cefazolin is a recommended antibiotic for prophylaxis after craniotomy, with a slightly greater expected survival compared to other strategies 3.
- Vancomycin is also a recommended antibiotic, particularly for patients with a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection 3, 4.
- Ampicillin/sulbactam is a recommended antibiotic for head and neck cancer surgery, with a potential protective effect against surgical site infections when prolonged beyond the day of surgery 5, 6.