Perioperative Antibiotic Selection and Duration in Endonasal Skull Base Surgery: Recommendations Based on 7 Years of Clinical Experience and Literature Review

Background: Perioperative antibiotic administration, one dose, is mandated by National Surgical Quality Improvement Program (NSQIP) and the Surgical Care Improvement Project (SCIP). Multiple recommendations are cited in the skull base surgery literature without an adopted consensus. We also noted that choice and duration of antibiotic regimens at our institution was not consistent.

Methods: Endonasal endoscopic skull base procedures were studied between 2007 and 2014. Antibiotic regimens and duration of administration were reviewed. Incidence of postoperative meningitis and associated risk factors were analyzed. PubMed published articles from 2000–2010 related to “Post Operative Meningitis” or “Antibiotic Recommendations: in Skull Base Surgery” were reviewed.

Results: Over 1500 endonasal endoscopic skull base cases were reviewed. Antimicrobial agent selection and duration were not consistent and were found to be surgeon preference specific. The incidence of postoperative meningitis was less than 1 percent. Risk factors associated with postoperative meningitis were identified. Prolonged operative time (> 6 hour) correlated with the surgical complexity and inappropriately long intervals between intraoperative antibiotic dosing were identified as possible risk factors. All patients received at least one preoperative dose of an antimicrobial agent in compliance with regulatory guidelines.

PubMed Literature review revealed different antimicrobial regimens. A brief summary of these regimens will be presented. In May 2015, based on our clinical experience, the literature review and consultation with infectious disease specialists, our institution adopted a standardized protocol for antimicrobial agent administration and duration. Complexity, duration of the procedure, nasal packing, lumbar drain placement, immunocompromised state and/or presence of coexisting sinusitis/skull base infection required prolonged postoperative antimicrobial therapy. Otherwise, patients received one antibiotic perioperative dose. Augmented penicillin-Ampicillin plus sulbactam (Unasyn 1.5- 3.0 g) or Fortaz (ceftazidime 2.0 g) are administered within 1 hour of the start of the procedure. In penicillin allergic patients, Azactam (aztreonam 2 g) is administered. If MRSA colonization is a concern (i.e.: nursing home resident). Vancomycin 1 g is additionally administered. Evidence-based medicine to support our institution’s protocol will be presented.

Conclusions: Each institution should review and adopt a standardized protocol for antimicrobial agent administration and duration of therapy supported by their clinical experience, infectious disease specialist consultation and evidence-based medicine doctrine