Empirically adapted or personalized antibiotic prophylaxis in select cranial neurosurgery?
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EDITORIAL (BY INVITATION) - PITUITARIES
Empirically adapted or personalized antibiotic prophylaxis in select cranial neurosurgery? Thomas Mindermann 1 Received: 26 August 2020 / Accepted: 27 August 2020 # Springer-Verlag GmbH Austria, part of Springer Nature 2020
Introduction The development of a safe and effective antibiotic prophylaxis in surgery has been developing since the 1970s. A few groundbreaking publications have led to today’s concept of single-dose or ultra-short antibiotic prophylaxis in most surgical interventions including cranial neurosurgery. Over the decades, a few basic rules of antibiotic prophylaxis have evolved such as the avoidance of antibiotics which are first choice therapeutic agents, their application before skin incision, the appropriate selection of antibiotic agents effective against the expected pathogens, and the application of a single-dose or an ultra-short prophylaxis rather than extended regimes. By following these rules, the risk of the emergence of resistant strains is reduced to a minimum while providing a good safeguard against postoperative infections without spoiling potential candidates for an antibiotic therapy in the case of infection. Lately, several publications have surfaced dealing with the question which particular prophylactic regime is adequate and if antibiotic prophylaxis in cranial neurosurgery should be individually tailored or not [1, 2, 7]. Is it time to abandon empirically adapted and proven regimes of antibiotic prophylaxis for personalized regimes in endonasal skull base surgery and other selected cranial interventions?
Historical context In this context, it is worthwhile to recollect briefly the historically most important publications for surgery and neurosurThis article is part of the Topical Collection on Pituitaries * Thomas Mindermann [email protected] 1
Klinik Im Park, Zurich, Switzerland
gery addressing antibiotic prophylaxis. In the decade from 1970 until 1980, Cruse and Foord introduced and established the concept of four different surgical categories with distinctly different risks of postoperative wound infection in the absence of antibiotic prophylaxis: (i) “clean” with a 1.5% risk, (ii) “clean-contaminated” with a 7.7% risk, (iii) “contaminated” with a 15.2% risk, and (iiii) “dirty” with a 40% risk of infection [4]. It became increasingly clear that about 80% of wound infections are caused by the patient’s own saprophytes of the skin or the mucosa, that the ideal timing for antibiotic prophylaxis is its application before skin incision, and that for obvious reasons no first-line therapeutics should be used for prophylaxis. In 1972, it was a prospective, controlled, and double-blind study in cardiac surgery which favored and established single-dose antibiotic prophylaxis over multipledose regimes in surgery of the “clean” category [3]. In 1985, a study published a wide risk of infections following clean cranial neurosurgery in the absence of antibiotic prophylaxis [8]. The authors showed that re-operations for gliomas had an 11% risk o
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