The Use and Misuse of Antibiotics in Neurosurgery

Neurosurgical patients often receive antibiotic therapy in the setting of procedural prophylaxis, empirical treatment of a presumed infection, or treatment of a confirmed infection. In all three situations, it is important to carefully consider both the benefits and the risks. Antibiotics have saved many lives, but their side effects, including increased drug resistance and adverse drug reactions, should not be taken lightly when one is deciding to administer these agents. Although Harvey Cushing reported only a single death due to postoperative infection in his series of 149 tumor operations, emphasizing that proper surgical sterile technique is essential, it is the standard of care in the postantibiotic era to administer prophylactic antibiotics if there is objective evidence to support their use. Antibiotics should be specifically chosen based on the risk of infection associated with the intended procedure. Expected infection rates based on the type of wound (clean, clean-contaminated, contaminated, or dirty) can help objectively guide decision making. In considering antibiotic treatment for a presumed or confirmed infection, the choice of antibiotic should be made by evaluating the most likely infecting organisms and then directed by culture results when available. Once antibiotics are selected, the risks must be frequently revisited and judiciously considered with every administration. Broad-spectrum antibiotic coverage should be switched to a more narrowed antibiotic regimen whenever culture results and sensitivities allow, and should be used for the shortest effective duration. The dose and frequency of administration should be guided by principles of pharmacokinetics and, in serious infections, by measured antibiotic levels. Antibiotic misuse can lead to a costly yet seemingly harmless expenditure, or it can lead to a consequence as grave as death from an adverse side effect and/or drug interaction. Adherence to the basic principles of appropriate use and consulting with infectious disease specialists can optimize and enhance the use of antibiotics in neurosurgical practice.