Parks_EU Neurology 10/03/2010 10:19 Page 117
Reduction of Surgical-site Infections in Neurosurgery
Figure 1: Time-dependent In Vitro Kill Rate, Expressed in Logarithms of Colony-forming Units Killed, for an
Antimicrobial-impregnated Incise Drape (3M™Ioban™2)
In vitro log kill loban 2
8.0
7.0
6.0
5.0
4.0
3.0
Logarithm killed organisms
2.0
1.0
0.0
30 60
90
Time of exposure (minutes)
S. aureus MRSA S. epidermidis MRSE E. faecalis VRE E. faecium MDR S. pyogenes E. cloacae
E. coli K. pneumoniae P. aeruginosa S. marcescens C. albicans C. parapsilosis
MDR = multidrug-resistant; MRSA = methicillin-resistant Staphylococcus aureus; MRSE = methicillin-resistant Staphylococcus epidermidis; VRE = vancomycin-resistant enterococcus.
mechanism by which to estimate the risk of infection for a given operative period,
20
but is not of any apparent value beyond that time-
procedure. However, neurosurgery is sufficiently different that a frame. In a single observational study, there was no benefit with the
modified system of infection classification appears justified.
13
In use of antibiotic-coated devices within the central nervous system.
21
patients beyond the neonatal period (where repair of neural tube However, there has been an association between bacterial density on
defects appears to represent a unique category of patient), the the skin and subsequent infection of cerebrospinal fluid shunts,
22
presence of implanted synthetic materials supports the separation of consistent with the principle that the risk of infection is proportional
this group of patients from ‘clean’ surgical cases due to a significantly to wound bacterial content.
higher infection rate.
By reducing contamination of the wound, 3M™Ioban™2 could reduce
It has been recognised for decades that reactions to implanted the infection rate due to surgeries of long duration, especially if
materials within the central nervous system are identical to reactions implantation of synthetic materials is to be carried out. Such
seen elsewhere in the body, with the addition of gliosis in the central a reduction would be consistent with published data on the 10-fold
nervous system superimposed on the more typical healing response reduction in wound contamination in orthopaedic surgery attributed
that leads to fibrosis.
14
Similarly, the prevention, diagnosis and to 3M™Ioban™2 use
23
– a reduction that can be observed with the
management of infections associated with implanted devices provide use of standard iodine-based pre-operative antisepsis.
24
challenges similar to those faced with orthopaedic or cardiovascular
devices.
15
The risk of infection is inversely related to host response, Reduction of skin flora is customarily achieved by the use of broad-
and the ability to resist infection is greatly diminished by the presence spectrum antiseptics. However, the response to antiseptic agents can
of a device. be highly individual in nature,
25
and it is also the case that no
antiseptic agent is capable of removing all organisms.
3
In the absence
Both
16,17
in vitro and
18
in vivo analyses have indicated that the presence of a known ‘minimum’ acceptable density of organisms, a reduction
of a foreign material results in a localised immune defect that in number of bacteria at the wound site to as low a number as
significantly reduces the host’s ability to respond to pathogens. possible is indicated. Since bacterial adherence is a pivotal step in
Infection by atypical pathogens of low virulence is commonly subsequent device-related infection,
26–28
providing a sterile surface by
associated with immune-compromised patients,
19
which further using incise drapes also appears beneficial.
supports the theory of a localised immunological defect at the site of
an implanted device. Current evidence supports the use of a sterile incise drape with
antimicrobial impregnated into the adhesive as a mechanism to
As is the case with implanted materials in other sites, the use of reduce the risk of surgical-site infection. Assessment of the efficacy
prophylactic antibiotics or antibiotic-coated materials has been of a subset of currently available surgical incise drapes was carried
considered. Analysis of prophylactic antibiotics indicates that out in vitro.
29
The results are illustrated in Figure 1 for the
protection against infection can be conferred for the 24-hour peri- antimicrobial-impregnated incise drape (3M™Ioban™2).
EUROPEAN NEUROLOGICAL REVIEW 117
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