- Department of Neurosurgery at Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
Raphael Vicente Alves
Department of Neurosurgery at Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
DOI:10.4103/2152-7806.64966© 2010 Alves RV This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Alves RV, Godoy R. Topical antibiotics and neurosurgery: Have we forgotten to study it?. Surg Neurol Int 30-Jun-2010;1:22
How to cite this URL: Alves RV, Godoy R. Topical antibiotics and neurosurgery: Have we forgotten to study it?. Surg Neurol Int 30-Jun-2010;1:22. Available from: http://sni.wpengine.com/surgicalint_articles/topical-antibiotics-and-neurosurgery-have-we-forgotten-to-study-it/
Background:For neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques. However, the efficacy of topical antibiotic prophylaxis in neurological operations remains to be established by neurosurgeons.
Methods:The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature. The authors performed the search by using the following Mesh terms: “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibiotic prophylaxis”; “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibacterial agents.”
Results:In the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery. All the papers reported were Class III evidence.
Conclusion:To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery.
Keywords: Antibiotic prophylaxis, neurosurgery, neurosurgical procedures, topical antibiotic
Evidence-based medicine may be defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.[
For neurosurgery, the last decades have been a time of incredible improvement in areas such as imaging, microscopy, endoscopy, stereotactic guidance, navigation, radiosurgery and endovascular techniques.[
The authors did an historical review of the literature regarding the utilization of topical antibiotic prophylaxis in neurological operations. The Pub Med database of the U.S. National Library of Medicine / National Institutes of Health was utilized as the primary source of the literature screened for development of this paper. The search was performed in January 2010, utilizing Pub Med files beginning in 1966 with no language limitation. The authors performed the search by using the following Mesh terms: “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibiotic prophylaxis”; “neurosurgery” or “neurosurgical procedures” and “administration, topical” and “antibacterial agents.” The articles were reviewed by title, abstract or full text to identify relevant publications on this subject. The reference lists of textbook chapters, review articles and articles identified in the primary search were also examined. Undesired papers were excluded from the initial basis set to develop the final working set. These excluded publications, although found by the search strategy, were papers that did not discuss the main topic of this research. The intention of this search was to find articles that provided data on topical antibiotic prophylaxis in neurosurgery.
The primary search identified only 4 articles after undesired papers were excluded.[
The articles were separated into 3 classes of evidence. Evidence from well-designed randomized controlled clinical trials, including overviews of trials, was classified as Class I. Evidence from well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies and other comparable studies, and from less well designed randomized controlled trials, was classified as Class II. Evidence from case series, comparative studies with historical controls, case reports, expert opinion and significantly flawed randomized controlled studies was classified as Class III.
The search identified 2 articles that compared topical and parenteral antibiotics prophylaxis with controls (only parenteral).[
Two studies compared topical antibiotic prophylaxis with a historical control without antibiotic prophylaxis,[
To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery [
Topical application was the first drug-administration route utilized by surgeons to control infection. The Edwin-Smith papyrus (1700 BC) is thought to be the oldest book on surgery.[
During the 1960s, 1970s and early 1980s, better-designed studies were reported that evaluated the use of antibiotic prophylaxis in neurological procedures. The goal of these papers was to study the importance of antibiotic prophylaxis, and they did not separate parenteral from topical to compare with a control group without prophylaxis,[
Maybe, the most important publication on this subject is a case series reported by Malis in 1979. The Malis technique of antimicrobial prophylaxis proposed preoperative parenteral administration of a single dose of vancomycin (1 g) and 80 mg of gentamicin (later 80 mg of tobramicin) and continuous irrigation of the surgical site with streptomycin (50 mg/L of saline).[
Haines reported in 1982 an excellent critic review of the literature about topical antibiotics and concluded that no scientifically valid study to either confirm or refute the possible value of this prophylaxis in clean neurosurgical procedures exists, but the subject justifies a carefully designed randomized clinical trial.[
In the 1990s, a greater number of papers were published on the subject. Maurice-Williams et al.[
In the same decade, Savitz et al. reported 3 case series using topical and parenteral antibiotic prophylaxis with no case of infection.[
Recently, Miller et al. reported a historical control study where they showed a significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin-polymyxin application in the wounds.[
Neurosurgeons have used topical antibiotics for several years in different forms, such as powder, spray, irrigation, wound local application, ointment after wound closure or combinations of these. Moreover, the drugs utilized and the sites where to apply the prophylaxis have varied in accord with generations and/ or neurosurgery departments. Some surgeons use topical antibiotics just before the wound closure; and others, during the whole procedure. There may be neurosurgeons that use topical antibiotics only in procedures with hardware. However, many neurosurgeons never use topical antibiotic prophylaxis. These differences reflect the insufficient knowledge about the subject.
Are topical antibiotics effective in preventing infection in neurological procedures? What type of infection: superficial, deep or both? Which are the better drugs? Are they secure to use in neural tissue? Will we have problems with bacterial resistance or superinfection? Some authors, especially Savitz SI and Savitz MH, took the initiative to answer some of these questions.[
In the last 70 years, we have poorly studied the use of topical antibiotics in neurosurgery, although it seems to be a common practice all around the world. All the papers reported were Class III evidence. The categorization as Class III does not imply erroneous or problematic information. These publications show that we need to study this subject better. Neurosurgeons are still without appropriate answers to questions formulated over the last two decades. Only with a better level of evidence, neurosurgeons will be able to integrate individual clinical expertise with the best available clinical evidence and practice evidence-based medicine. We are going (slowly) in the right direction, but neurosurgeons are still far from answers to questions about the appropriate use of topical antibiotics in neurological operations. The first step has been taken; it is time to take the second.
All the publications identified by the search were Class III evidence. To the best of our knowledge, there is no publication that provided Class I or II evidence about topical antibiotic prophylaxis in neurosurgery.
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