Controversies in Perioperative Antimicrobial Prophylaxis

Brooke K. Decker, M.D.; Alexander Nagrebetsky, M.D.; Pamela A. Lipsett, M.D.; Jeanine P. Wiener-Kronish, M.D.; Naomi P. O'Grady, M.D.


Anesthesiology. 2020;132(3):586-597. 

In This Article


A randomized, prospective, multicenter trial is underway assessing the safety and efficacy of topical vancomycin in neurosurgical patients undergoing a craniotomy or noninstrumented spine procedures. A report on the adverse events and microbiology profiles from the first year of enrollment has just been published.[114] Systemic absorption of the topical vancomycin was monitored by measuring serum vancomycin levels at 6 and 20 h after wound closure. Microbial cultures were done of the anterior nares and surgical site before draping, 48 h after wound closure, and at 2 weeks and 3 months after surgery. Serious adverse events were reported in 5 of 257 control patients and 2 of 514 patients who were in the treatment group; therefore, no significant difference in serious adverse events or adverse events occurred between the groups. Serum vancomycin levels in patients who received topical vancomycin but no intravenous vancomycin were 6.3 ± 1.8 micrograms/ml. Microbiologic studies documented that topical vancomycin did not change the risk of S. aureus colonization after cranial surgery in an interim report, but final results are still pending.[114]

External Ventricular Drains

A consensus statement has been formulated by the Neurocritical Care Society (Chicago, Illinois) given the paucity ofhigh-quality clinical data. The group involved included neurologists, neuroinfectious experts, internists, pharmacotherapy professionals, and nurses.[115] The infection rates of external drains have been reported between 0 and 32% with typical rates of about 10%.[115] The definition of infection varies; the Centers for Disease Control and Prevention do not require positive cerebrospinal fluid cultures, whereas other authors do.[116,117]

The recommendation from the Neurocritical Care Society was for one dose of antimicrobials before external ventricular drain insertion (low-quality evidence); they recommended against the use of antimicrobials for the duration of external ventricular drain placement (low-quality evidence). The Neurocritical Care Society did recommend using antimicrobial-impregnated catheters (moderate-quality evidence) and using intraventricular antimicrobials to treat ventriculostomy-related infections when there was a failure to respond to intravenous antibiotics or the organisms involved had very high minimum inhibitory concentrations that would be difficult to achieve in the cerebrospinal fluid (moderate-quality evidence).[115] More recent studies have confirmed that prolonged antibiotics are associated with an increase in nosocomial infections[118] and do not provide more protection.[119]


Significant controversies in antimicrobial prophylaxis remain, and there are numerous opportunities for improving practice through rigorously designed and implemented studies. More antibiotics are not always more effective in reducing surgical site infection. There are significant gaps between guidelines and practices, predominately with duration of antibiotic prophylaxis exceeding current consensus guidelines.