J Neurol Surg B Skull Base 2021; 82(04): 425-431
DOI: 10.1055/s-0040-1713771
Original Article

Is a Single-Dose, Single-Agent Perioperative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 10-Year Review of 422 Cases

Mark A. Hughes
1   Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
,
Nick Phillips
1   Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
,
Atul Tyagi
1   Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
,
1   Department of Neurosurgery, Leeds General Infirmary, Leeds, United Kingdom
,
Kavita Sethi
2   Department of Microbiology, Leeds General Infirmary, Leeds, United Kingdom
,
Paul Nix
3   Department of Ear, Nose and Throat Surgery, Leeds General Infirmary, Leeds, United Kingdom
› Author Affiliations

Abstract

Objective Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the safety of a single-agent, single-dose protocol.

Design, Setting, and Participants A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies.

Main Outcome Measures Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery.

Results Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33).

Conclusion For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.



Publication History

Received: 04 December 2019

Accepted: 27 April 2020

Article published online:
01 July 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Shibao S, Toda M, Tomita T. et al. Analysis of the bacterial flora in the nasal cavity and the sphenoid sinus mucosa in patients operated on with an endoscopic endo- nasal transsphenoidal approach. Neurol Med Chir (Tokyo) 2014; 54: 1009-1013
  • 2 Jin Y, Liu X, Gao L. et al. Risk factors and microbiology of meningitis and/or bacteremia after transphenoidal surgery for pituitary adenoma. World Neurosurg 2018; 110: e851-e863
  • 3 Brown SM, Anand VK, Tabaee A, Schwartz TH. Role of perioperative antibiotics in endoscopic skull base surgery. Laryngoscope 2007; 117 (09) 1528-1532
  • 4 van Aken MO, de Marie S, van der Lely AJ. et al. Risk factors for meningitis after transsphenoidal surgery. Clin Infect Dis 1997; 25 (04) 852-856
  • 5 Little AS, White WL. Short-duration, single-agent antibiotic prophylaxis for meningitis in trans-sphenoidal surgery. Pituitary 2011; 14 (04) 335-339
  • 6 Lai LT, Trooboff S, Morgan MK, Harvey RJ. The risk of meningitis following expanded endoscopic endonasal skull base surgery: a systematic review. J Neurol Surg B Skull Base 2014; 75 (01) 18-26
  • 7 Kono Y, Prevedello DM, Snyderman CH. et al. One thousand endoscopic skull base surgical procedures demystifying the infection potential: incidence and description of postoperative meningitis and brain abscesses. Infect Control Hosp Epidemiol 2011; 32 (01) 77-83
  • 8 International medical products price guide. Retrieved October 2019 at: http://mshpriceguide.org/en/single-drug-information/?DMFId=48&searchYear=2015
  • 9 Milanese L, Zoli M, Sollini G. et al. Antibiotic prophylaxis in endoscopic endonasal pituitary and skull base surgery. World Neurosurg 2017; 106: 912-918
  • 10 Guo K, Heng L, Zhang H, Ma L, Zhang H, Jia D. Risk factors for postoperative intracranial infections in patients with pituitary adenoma after endoscopic endonasal transsphenoidal surgery: pneumocephalus deserves further study. Neurosurg Focus 2019; 47 (02) E5