Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis

Abstract

Background: Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. Methods: The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. Results: Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. Conclusions: Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study

“…It has been reported that craniotomy, albeit uncommonly, can be associated with the development of SSIs, such as epidural empyema, meningitis, subdural empyema or cerebral abscess [ 9 , 10 , 11 , 12 , 13 ]. Similarly, in craniosynostosis, defined as premature fusion of one or more cranial sutures with an estimated prevalence of 3 to 7.2 per 10,000 live births [ 14 ], a tailored treatment approach is of paramount importance, and risk of SSIs can vary from 0.8% to 7% according to the type of surgery and patient characteristics [ 15 ]. Staphylococci are the most common etiologic agents in epidural infections.…”

Secondary Corrections for Single-Suture Craniosynostosis: Perioperative Outcomes and Predisposing Factors

“…It has been previously suggested that reoperations are associated with higher infection rates. 21,22 Although longer term follow-up would provide a clearer picture of outcomes, thus far, no patients undergoing secondary repairs have required any tertiary corrections. It is hoped that because these secondary corrections took place at a mean age of 4.5 years, at which time approximately 75% of lifetime increases in head circumference had already taken place, the potential for recurrent deformities and/or the development of elevated intracranial pressure should be lower.…”

Management of Epidural and Subgaleal Abscesses in Pediatric Craniosynostosis Surgery

“…Recent studies have highlighted the increased complications associated with BFOA compared to CVR. 2,15,16,[19][20][21][22][23][24] In the BFOA procedure, advancement of the frontal bandeau and associated skull volume expansion creates a "non-collapsing dead space" between the newly advanced forehead and the brain. While the brain eventually comes forward to obliterate this space, we feel certain that all patients develop a transient fluid collection in this space in the early postoperative period.…”

“…3 Yeung et al in their retrospective study, found that complicated diagnoses were associated with a higher risk of surgical site infection, as some of the patients had to go through multiple procedures. 15,16 In addition, while recent studies document superficial wound infections, epidural and subgaleal abscesses, to our knowledge there have been limited recommendations on the clinical management of deep space SSIs. Bones comprise an important component of facial anatomy, therefore salvage is important in pediatric craniofacial reconstruction.…”