Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon’s cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children’s Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children’s hospital (All Children’s Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03–0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04–0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05–9.50, p = 0.04, and HR 2.82, 95% CI 1.33–5.96, p = 0.007, respectively).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.</jats:p></jats:sec>

Complications associated with bacitracin powder in surgical wounds

“…Our retrospective analysis of shunt infection over 10 years, divided between periods when bacitracin was and was not used, suggested that a reduction in shunt infection was at least partially associated with the use of bacitracin powder. 4 However, given the limitations of a retrospective study, prospective controlled trials are required before this practice can be broadly recommended. We conducted the analysis in this report to further study the possible complications associated with applying high-dose bacitracin directly to surgical wounds prior to closure.…”

“…In the current study, we reanalyzed the same patient cohort previously used to study the effect of bacitracin powder on CSF shunt infection rates in children over a 10-year period. 4 Of the 658 patients who underwent surgery by the corresponding author (G.F.T.) at All Children's Hospital during that time period, we previously reported on 539 patients who had at least 180 days of follow-up, to assess shunt infection.…”

“…Please refer to our previous study for the precise surgical technique. 4 Renal function was determined by recording preoperative creatinine and estimated glomerular filtration rate (eGFR) and comparing those values to both the immediate postoperative and 3-month follow-up. The glomerular filtration rate was estimated using the modified Schwartz estimating equation [eGFR = (0.413 × height [in cm])/ serum creatinine (mg/dl)].…”

“…The only protective factor for shunt infection was the application of bacitracin powder just prior to wound closure. 4 Future randomized controlled trials have been suggested before the use of topical antibiotics can be widely recommended.…”

“…[18][19][20]23,30 However, the potential adverse effects from topical administration of bacitracin into wounds has not been extensively studied. To more thoroughly address these concerns, we further scrutinized the medical records from our patient cohort in the bacitracin powder shunt study, 4 specifically analyzing patient outcomes related to the potential complications of using topical high-dose bacitracin powder.…”