Vacuum Sealing Drainage against surgical site infection after intracranial neurosurgery: a technical note

doi:10.21203/rs.3.rs-3452479/v1

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Vacuum Sealing Drainage against surgical site infection after intracranial neurosurgery: a technical note

https://doi.org/10.21203/rs.3.rs-3452479/v1

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Background: Surgical site infections (SSIs)are still a challenge to neurosurgeons. However, Vacuum Sealing Drainage (VSD), which has been used extensively in the treatment of various infections after surgery, looks a promising solution. This study examines the efficacy and outcome of VSD treatment of pyogenic SSIs following intracranial neurosurgery.

Methods: 20 patients with infections who underwent surgical intervention were treated retrospectively using VSD at the Zhongnan hospital of Wuhan University over the past five years. Primary surgery types, SSI types, VSD replacements, surgical procedures, pathogenic germs, antibiotic therapy and infection control were reviewed and discussed.

Results: Of the 20 infections, 13 (65%) were extradural, and 7 (35%) were extradural SSIs combined with intracranial infections (including 5 meningitis, 1 subdural abscess, and 1 brain abscess). All the patients consented to medical device implantation (including 5 titanium webs, 6 bone flap fixation devices and 12 dura-plasties), with most of the devices removed during debridement. The median duration from primary surgery to a SSI diagnosis was 19 days (range: 7 to 365 days). All the patients also agreed to debridement and VSD treatment; VSD was replaced 0 to 5 times (median, one time) every 4 to 7 days and retained for 4 to 35 days (median, 14 days). Seven (35%) patients had defined bacterial infections, with staphylococcus aureus the dominant infection. The deployed standard VSD and antibiotic treatment ensured full recovery from SSIs, including from intracranial infections: 14 (70%) patients were free of infection during follow-up, and no infection-associated death was registered; 6 (30%) patients died of severe primary affections.

Conclusion: VSD-assisted therapy is safe and effective against SSIs after intracranial neurosurgery.

Vacuum Sealing Drainage

Surgical site infection

intracranial infection

neurosurgery

Debridement

Although brain surgery technology and asepsis have seen significant developments in recent times, surgical site infections (SSIs) after intracranial neurosurgery sometimes persist and remain a worldwide clinical problem[1, 2]. Different centers and countries have reported varied rates of SSIs, ranging from < 1% to > 8%[2–5]. Identified risk factors of SSIs after intracranial neurosurgery are as follows: the female sex, cerebrospinal fluid (CSF) leak, CSF drainage, the duration of operation, prior same-side craniotomy, prosthetic implants, procedures on dry skin antiseptic, and so forth[6–9]. A SSI often results in pain, altered consciousness, prolonged hospital stays, increased expenses, permanent sequelae, and significant morbidity and mortality.

SSIs post-neurosurgery have been classified into two categories of extradural and intradural infections[10]. Some studies have also grouped SSIs into superficial incisional SSIs, deep incisional SSIs, and organ/space SSIs[3, 11, 12]. Extradural SSIs includes skin or subcutaneous tissue infection, soft tissue (fascia and muscle layer) infection, aponeurosis/skull bone infection, and epidural infection, during which a patients’ cerebral dura mater is completely intact and sealed off without symptoms of an intracranial infection. Extradural SSIs are treated mainly with antimicrobial therapy, medical implant removal, debridement and drainage[10, 13]. Intradural SSIs are recognized specifically as intracranial infections (a brain abscess, a subdural abscess, meningitis, encephalitis and ventriculitis), which is severe and rapidly progressive. These severe postoperative complications require immediate and vigorous medical and/or surgical interventions, such as long-term antibiotic therapy, abscess excision or incision drainage, external ventricular drainage (EVD), and lumbar cistern drainage (LCD)[14–16]. Extradural and intradural SSIs typically occur simultaneously once the cerebral dura mater has been destroyed, a problematic and life-threatening clinical challenge to neurosurgeons.

SSIs with focal pyogenic infections, such as subcutaneous tissue abscesses, subdural empyema and brain abscesses, can be treated effectively and as required with surgical treatment. In most cases, excision and/or drainage of abscesses can adequately ensure the healing of pyogenic SSIs. Reportedly, a closed-incisional negative pressure therapy eases surgical site infections (SSIs) in spine surgery[17], and negative pressure wound therapy is arguably more effective against SSIs after vascular, abdominal, orthopaedical, and thoracic surgeries than conventional procedures[18]. Vacuum sealing drainage (VSD), a core technique of negative pressure wound therapy, demonstrably exerts therapeutic efficacies against SSIs following spinal surgeries and multiple wound infections[19–21]. However, the efficacy and outcome of VSD against SSIs after intracranial neurosurgery is still to be investigated fully.

The present study retrospectively reviews the severe SSI cases treated in our department over the past five years. The investigation focused primarily on the patients with soft tissue abscesses combined with/without intracranial infections, who were treated surgically using VSD. The efficacy of the technique and postoperative outcomes are presented and discussed in this study.

Study design and population

This retrospective study was conducted at the Neurosurgery department of the Zhongnan hospital of Wuhan University. The protocol was reviewed and approved by the Medical Ethics Committee of Zhongnan Hospital of Wuhan university and applied in accordance with the Declaration of Helsinki. Consecutive patients with pyogenic SSIs after intracranial neurosurgery treated at the institution between March 2018 and May 2023 made up the patient group. All the patients presented with severe soft tissue abscesses and needed surgical intervention with VSD. Surgical and antimicrobial treatments were performed following a standardized algorithm. An interdisciplinary team consisting of infectiologists, pharmacists and neurosurgeons was set up to evaluate every patient with a SSI. Data were collected from electronic medical charts and organized in a standardized case report form.

Definition of SSI

Based on the criteria established by the Centers for Disease Control and Prevention (CDC) in 2023[22, 23], a SSI was defined as any infection occurring within 30 or 90 days after the NHSN operative procedure or up to one year when prosthetic materials are implanted.

Extradural SSIs in this study, including skin or subcutaneous tissue infection, soft tissue (fascia and muscle layer) infection, aponeurosis/skull bone infection, and epidural infection, had to meet at least one of the following criteria: 1) purulent wound discharge; 2) organism(s) identified from an aseptically-obtained specimen; 3) local signs or symptoms of an infection, such as localized pain, tenderness, swelling or heat; 4) CT scanning or MRI showing subcutaneous tissues or epidural abscesses; 5) depiction of wound infections during surgery by neurosurgeons.

Intracranial infections, including brain abscesses, subdural abscesses, meningitis, encephalitis and ventriculitis, had to meet at least one of the following criteria: 1) organism(s) identified from an CSF or intracranial abscess specimen; 2) typical symptoms of high fever, headache, meningeal signs, dysfunction of cranial nerves and altered consciousness without other recognized causes; 3) increased white cell counts, decreased glucose levels, and elevated proteins in the CSF; 4) CT scanning or MRI showing brain and subdural abscesses; 5) depiction of intracranial infections during surgery by neurosurgeons.

Surgical and Antimicrobial Treatment

Pyogenic extradural SSIs were treated with empirical antibiotic therapy immediately after the diagnosis of SSIs, followed by surgical treatment of the original incision, and then a standardized protocol, such as preoperative hair removal and antibiotic therapy. The pus, necrotic tissues, inflammatory granulation, and scar tissues were excised, and the wound was flushed alternately with 3% hydrogen peroxide, diluted povidone iodine, and normal saline at least three times. Next, sub-healthy tissues were eliminated, and the dead space was excavated completely. Lastly, the wound was flushed repeatedly and stanched fully, and VSD was deployed. The VSD product was replaced every 4 to 7 days until the wound surface was fresh and new granulation tissues were covered adequately. Upon successfully and completely curbing the infection, as well as the effective generation of new granulation tissues, the deep soft tissue was repaired, and the skin flap was sutured. Wound vacuuming was kept at between − 20 and − 40 kPa.

Pyogenic extradural SSIs combined with intracranial infections were also treated with surgical intervention employing VSD following the procedure above (Fig. 1). Antibiotics (vancomycin for gram-positive bacteria and meropenem for gram-negative bacteria) with good penetration properties into brain tissues or meninges were used intravenously and intrathecally for 4 to 6 weeks and were adjusted according to the drug sensitivity test. Lumbar cistern drainage was conducted regularly for CSF drainage and intrathecal injection. Intracranial abscesses, such as subdural empyema and brain abscesses, were excised and drained, and bone flaps and medical materials were removed. Wound vacuuming was kept at -20 kPa to avoid excessive CSF loss.

Follow-up Evaluation

Clinical signs or symptoms, intercurrent surgical procedures, drug use, disease chronicity treatment, and general health status were evaluated during follow-up visits. Patients were declared infection-free if every one of the following criteria were met: 1) no signs or symptoms of recurrent infections; 2) no requirement of antimicrobial therapy; 3) no laboratory-determined signs of recurrent abscesses; 4) no infection-related deaths; and 5) no subsequent need for surgical interventions against infections.

Characteristics of the patients and infection

Demographics, Clinical Symptoms, and Laboratory Findings vis-à-vis SSIs after intracranial neurosurgery are detailed in Table 1. Of the 20 patients with SSIs, 13 (65%) were diagnosed with extradural SSIs (including one skin or subcutaneous tissue infection, two skull bone infections, six epidural infections and four titanium web-associated infections), 7 (35%) with extradural SSIs combined with intracranial infections (including five meningitis, one subdural abscess, and one brain abscess). All the patients presented with local signs of an infection and purulent wound discharges. All 7 patients with intracranial infections presented with high fever, headache, meningeal symptoms, increased white cell counts, decreased glucose levels, and elevated proteins in the CSF; 5 (71%) of them exhibited altered consciousness. Six (46%) of the patients with extradural SSIs and only 1 (14%) with an intracranial infection had normal white blood cell counts and PCT levels.

Table 1

Demographics, Clinical Symptoms, and Laboratory Findings in 20 Patients with SSIs After Intracranial Neurosurgery
characteristics	All patients (n = 20)	extradural SSI (n = 13)	extradural and intradural SSI (n = 7)
Age/yeas old Male (Female) Tobacco smoking Diabetes CSF leak Clinical signs of infection Local signs Purulent wound discharge Fever Headache Meningeal signs Altered consciousness Laboratory findings Elevated WBC count Elevated PCT CSF testing increased cell count decreased glucose level decreased chloride level Elevated protein level Type of intradural SSI Meningitis Subdural abscess Brain abscess Type of primary surgery Craniectomy Cranioplasty Sphenotresia Reasons for primary surgery Brain trauma Intracranial hematoma Skull defect Brain tumor	49 (21–71) 14 (6) 7 1 4 20 20 9 11 7 5 7 11 7 7 7 5 5 1 1 13 5 2 3 8 5 4	52 (29–68) 9 (4) 4 1 2 13 13 2 4 0 0 3 5 NA NA NA NA NA NA NA 8 4 1 2 4 4 3	43 (21–71) 5 (2) 3 0 2 7 7 7 7 7 5 4 6 7 7 7 5 5 1 1 5 1 1 1 4 1 1
CSF: cerebrospinal fluid; WBC: white blood cell; PCT: procalcitonin; SSI: surgical site infection.

Characteristics of primary surgery

As showing in Table 1, three patients with brain trauma were subjected to decompression and evacuation of intracranial hematoma operations. Eight patients suffered intracranial hematoma, with four of them submitting to decompression and evacuation of intracranial hematoma operations and two each of the remaining four undergoing the evacuation of intracranial hematoma operation and the trepanation and drainage operations, respectively. Five patients agreed to the titanium web-using cranioplasty operation. Four patients with brain tumors (including two gliomas, one meningioma, and one craniopharyngioma) received tumor resection operations. The median time taken to perceive SSIs post-neurosurgery was 30 days in extradural SSIs and 10 days in intracranial infections (Table 2).

Table 2

Surgical and Antimicrobial Treatments and Outcomes in 20 Patients with SSIs After Intracranial Neurosurgery
characteristics	All patients (n = 20)	extradural SSI (n = 13)	extradural and intradural SSI (n = 7)
Prosthetic implants Bone flap and fixation device Duraplasty Titanium web Microbiology Monomicrobial infection Polymicrobial infection No growth Surgical treatment Debridement and VSD Excision of intracranial abscess Removal of foreign material Retention of foreign material Number of VSD change, median (range) Time of VSD coverage, days, median (range) Duration from primary surgery until SSI, days, median (range) Treatment outcome Duration of follow-up, months, median (range) Infection-associated deaths Infection-free state Died for other causes	6 11 5 2 5 13 20 2 9 2 1 (0–5) 14 (4–35) 19 (7-365) 18.0 (4.4–67.8) 0 14 6	5 8 4 1 1 11 13 0 7 2 1 (0–3) 14 (7–35) 30 (14–365) 23.1 (5.9–63.9) 0 10 3	1 4 1 1 4 2 7 2 2 0 1 (0–5) 12 (4–30) 10 (7–20) 11.3 (4.4–67.8) 0 4 3

Etiology examination and antimicrobial Treatment

The overall pathogen detection rate was low. Of the 13 patients with extradural SSIs, clear microorganism infections were detected in only 2 of them (Table 2): one was infected with enterobacter cloacae, and the other with enterobacter cloacae and staphylococcus capitis, all of which were very sensitive to antibiotics, like cephalosporin and levofloxacin. All these patients agreed to an empirical antibiotic therapy (including second and third generation cephalosporins, piperacillin-tazobactam, and levofloxacin), with the antibiotics adjusted according to the drug sensitivity test. Of the 7 patients with intracranial infections, clear microorganism infections (including two staphylococcus aureus, one enterococcus faecium, one extensively-drug resistant klebsiella pneumoniae, and one staphylococcus aureus with pseudomonas aeruginosa) were detected in the CSF of 5 of them. These patients were given vancomycin and meropenem for at least four weeks, with antibiotics adjusted to polymyxin and meropenem against extensively-drug resistant klebsiella pneumoniae.

Surgical treatment

All the patients agreed to debridement and VSD (Table 2). Of the 5 patients with cranioplasty, 3 consented to titanium web removal because of the severity of the infections and lengthy implantation, and 2 approved of titanium web retention after complete debridement. The bone flaps and bone fixation devices were removed in patients with osteomyelitis and subdural abscesses. Intracranial abscesses were excised and drained. VSD was replaced every 4 to 7 days, with the median number of VSD used for every patient equaling two, and the median duration for VSD application being 14 days. Five patients with intracranial infections consented to LCD, and one acquiesced in EVD for CSF drainage and the injection of antibiotics.

Outcome

After a median follow-up period of 18 weeks (Table 2), all the patients were declared free of infection. Three patients with extradural SSIs died of recurrent glioma, hydrocephalous, and recurrent chronic subdural hematoma, respectively, while three patients with intracranial infections died of a prolonged deep coma. No patient died of an infection.

This retrospective study examined 20 patients who underwent debridement and VSD to treat surgical site infections after intracranial neurosurgery. The outcome shows that the deployed standard surgical and antimicrobial treatments completely subdued and cured the pyogenic infections. No patient endured a recurrent infection and/or an infection-related death during follow-up.

Prosthetic implants are an important risk factor for SSIs after first-time neurosurgery[8, 24]. Here, all the patients consented to the implantation of medical devices, including a bone flap fixation device, a titanium web and artificial dura mater. Five (20%) patients with a titanium web implantation contracted SSIs, which is a considerable proportion, since the percentage of patients acquiescing in cranioplasty in the department was low. The rates of SSI contractions following cranioplasty differ among investigations, ranging from 5.89–9.9%[25–27]. Reportedly, the leading causative pathogen associated with neurosurgical implant infections is staphylococcus aureus[25].In this study, the current investigation found that two patients with cranioplasty had defined bacterial infections, including one staphylococcus aureus and one enterococcus faecium. The positive rate of bacterial culture here was only 35%, with staphylococcus aureus accounting for the highest proportion, consistent with previous findings[3, 10]. Hence, preventing SSIs during neurosurgery, especially cranioplasty, requires paying more attention. In a recent study, a low-cost wound healing protocol (consisting of vitamin and mineral supplementations, fluid supplementation, and oxygen support) reduced post-cranioplasty infection rates [28].

Although widely applied against various organ and tissue infections[18, 29], VSD has rarely been reported to exert efficacy against SSIs following intracranial neurosurgery. Allegedly, VSD is efficient against primary thoracolumbar spondylodiscitis[30] and SSIs after posterior spinal internal fixation[19]. In this investigation, the applied standard surgery with VSD ensured total restraint and cure of all patient infections, including infections in some patients who succumbed to traditional debridement and drainage treatment failure (Fig. 2). An average of two replacements of VSD, as well as fourteen days of its application, realized swift infection suppression and fresh granulation generation, undoubtedly shortening hospital stays and reducing costs. Astonishingly, VSD seems to contribute to the curbing of intracranial infections without inducing excessive CSF loss. All patients with intracranial infections benefited from VSD coverage, with the underlying mechanisms potentially being full drainage, increased local oxygen, and improved microcirculation by VSD, as well as VSD’s local anti-inflammatory capacity, all of which require further inquiry. Furthermore, VSD has been shown to reduce the rate of SSIs[31], particularly after spinal surgery[17, 32]. Therefore, VSD’s efficacy in preventing SSIs in patients at high risks of infection after intracranial neurosurgery requires the attention of scholars.

Despite the hugely impressive findings, this study had a couple of limitations. First, it was a single-center study with few samples. Second, it was a retrospective observational investigation without a control group, making it impossible to determine whether the high treatment success reflected the true efficacy of VSD, even if the patients who succumbed to treatment failure from traditional therapy recovered fully after VSD. Therefore, prospective studies comparing the efficacy of VSD-assisted treatment to traditional treatment against SSIs post-intracranial neurosurgery are warranted.

VSD is safe and effective against severe SSIs after intracranial neurosurgery, with short- and medium-term follow-ups attesting its excellent efficacy. To our limited knowledge, this is the first time discussing the effectiveness and outcome of VSD against SSIs after intracranial neurosurgery. Prospective controlled studies are, hence, needed to verify the results of this investigation.

SSIs

surgical site infections

VSD

vacuum sealing drainage

CSF

cerebrospinal fluid

EVD

external ventricular drainage

LCD

lumbar cistern drainage

CDC

centers for disease control and prevention.

Acknowledgements

Not applicable.

Authors’ contributions

SR and YL: conception and design, collection and/or assembly of data, data analysis and interpretation, and manuscript writing. XYS, QW and XHW: collection and/or assembly of data. CM, ZWX, ZL and RG: study materials provision, data analysis and interpretation. JCC and WW: conception and design, financial support, and final approval of manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Fundamental Research Funds for the Central Universities (2042022kf1142).

Data availability

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors.

Ethics approval and consent to participate

This retrospective study was approved by the Medical Ethics Committee of Zhongnan Hospital of Wuhan university and applied in accordance with the Declaration of Helsinki. The need for informed consent was waived by the Medical Ethics Committee of Zhongnan Hospital of Wuhan university for this retrospective study.

Consent for publication

Not applicable.

Authors’ information (optional)

Not applicable.

Conflict of interest

The authors declare that they have no competing interests.

Disclosures

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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No competing interests reported.

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Vacuum Sealing Drainage against surgical site infection after intracranial neurosurgery: a technical note

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