Systematic Review, Meta-Analysis and Grading of Evidence on the Effectiveness of Antimicrobial Prophylaxis for Neurosurgical Site Infections

Sylvia A Opanga, Mercy N Mulaku, Faith A Okalebo, Nimrod J Mwang’ombe, Kimani AM Kuria


Background: Antimicrobial prophylaxis is crucial for neurosurgical procedures, even though they are clean procedures. Observational studies have shown the effectiveness of different antibiotics in preventing neurosurgical site infections, but there remains paucity of systematic reviews and meta-analyses which have assessed their effectiveness in East Africa.

Objectives: To generate and appraise the quality of evidence that would inform antimicrobial prophylaxis in neurosurgery.

Methodology: A systematic review and meta-analysis was conducted between October 2014 and December 2015. Studies that involved the administration of systemic antibiotics for prophylaxis, use of antibiotic impregnated shunt catheters among adult patients aged over 18 years were included and subjected to abstract, title and full text screening. A meta-analysis was carried out using RevMan (Review Manager) version 5 software. The quality of evidence was evaluated using the GRADE system.

Results: One systematic review of randomized controlled trials (n=17) and 11 randomised controlled trials were included in the study. From the first meta-analysis, use of systemic antibiotics demonstrated an overall protective effect of 52% from development of surgical site infections [OR 0.48 (95% CI 0.30, 0.79)]. In the second meta-analysis, the use of antibiotic impregnated shunt catheters was associated with a higher risk of mortality compared to use of the standard shunt [(OR 1.47(95% CI 0.82, 2.62)]. Following evaluation of quality of evidence, in the antibiotics versus placebo arm, the quality of evidence was moderate, while that for antimicrobial impregnated shunts was very low.

Conclusion: Antimicrobial prophylaxis using systemic antibiotics or antimicrobial impregnated shunts is effective in preventing neurosurgical site infections. Antimicrobial impregnated shunts are too expensive for our study population.

Key words: systematic review, meta-analysis, antimicrobial prophylaxis


Abla AA, Zabramski JM and Jahnke HK (2011). Comparison of two antibiotic-impregnated ventricular catheters: a prospective sequential series trial. Neurosurg. 68: 437-442.

Alleyne CH, Hassan M and Zabramski JM (2000). The efficacy and cost of prophylactic and periprocedural antibiotics in patients with external ventricular drains. Neurosurg. 47: 1124-1127.

Bayston R, Bannister C and Boston V (1990). A prospective randomised controlled trial of antimicrobial prophylaxis in hydrocephalus in shunt surgery. Z. Kinderchir. 45: 5-7.

Blomstedt GC (1985). Trimethoprim-sulfamethexazole prophylaxis in ventriculostomy and shunting procedures.A double-blind randomized trial. J. Neurosurg. 62:694-7.

Bratzler D.W, Dellinger E.P and Olsen K.M (2013). Clinical Practice guidelines for antimicrobial prophylaxis in surgery. Am. J. Health. Syst. Pharm. 70:195-283.

Bullock R, Van Dellen JR and Ketelbey W (1988). A double-blind placebo-controlled trial of perioperative prophylactic antibitics for elective neurosurgery. J. Neurosurg. 69:687-91.

Chiang HY, Kamath AS and Pottinger JM (2014). Risk factors and outcomes associated with surgical site infections after craniotomy and craniectomy. J. Neurosurg. 120: 509-521.

Cochrane (2013). Cochrane handbook for systematic reviews of interventions. (Accessed 30.3.2016).

Cui Z, Wang B and Zhang Z (2015). Impact of antibiotic and silver-impregnated external ventricular drains on the risk of infections: a systematic review and meta-analysis. Am. J. Infect. Ctrl. (Accessed 30.3.2016).

Dellamonica P and Benard E (1993). Fluoroquinolones and surgical prophylaxis. Drugs. 45: 102-113.

DiPiro JT, Cheung RP and Bowden TA (1986). Single dose systemic antimicrobial prophylaxis of surgical wound infections. Am. J. Surg. 152: 552-559.

Djindjian M. (1994). Antimicrobial prophylaxis in neurosurgery. Ann. Franc. d’ Anesthesie. Reanim. 13: S93-95.

Djindjian M, Fevrier MJ and Otterbien G (1986). Oxacillin prophylaxis in cerebrospinal fluid shunt procedures: results of a randomized open study in 60 hydrocephalic patients. Surg. Neurol. 25:178-80.

Djindjian M, Lepresle E and Homs JB (1990). Antimicrobial prophylaxis during prolonged clean neurosurgery.Results of a randomized double-blind study using oxacillin. J. Neurosurg. 73: 383-6.

Everett ED and Strausbaugh LJ (1980). Antimicrobial agents and the central nervous system. Neurosurg. 6: 691-714.

Eymann R, Chehab S and Strowitzki M (2008). Clinical and economic consequences of antibiotic impregnated cerebrospinal fluid shunt catheters. J. Paed. Neurosurg. 1: 444-450.

Farber SH, Parker S.L and Adogwa O (2011). Effect of antibiotic-impregnated shunts on infection rate in adult hydrocephalus: a single institution’s experience. Neurosurg. 69: 625-9.

Fujiwara K, Suda S and Ebina T (2000). Efficacy of antimicrobial prophylaxis in clean neurosurgical operations: a comparison of seven day versus one day administration. No. Shinkei. Geka. 28: 423-427.

Gordis L (2014). Epidemiology and Public Policy: Meta-analysis. In Epidemiology. 5th Edition. 360-361. Elsevier.

Govender ST, Nathoo N, and van Dellen JR (2003). Evaluation of antibiotic-impregnated shunt system for the treatment of hydrocephalus. J. Neurosurg. 99:831-9.

GRADEpro GDT 2015. GRADEpro Guideline Development Tool [software] (2015): .McMaster University, [developed by Evidence Prime Inc]. Available from (Accessed 1/12/2015).

Guglielmo BJ, Hohn DC and Koo PJ (1983). Antimicrobial prophylaxis in surgical procedures. A critical analysis of the literature. Arch. Surg. 118: 943-955.

Gutierrez- Gonzalez R, and Boto GR (2010). Do antibiotic-impregnated catheters prevent infection in CSF diversion procedures? Review of the literature. J. Infect. 61: 9-20.

Haines SJ (1989). Efficacy of antimicrobial prophylaxis in clean neurosurgical procedures. Neurosurg. 24: 401-405.

Hoffman T, Bennett S and Del Marc C (2013). Evidence based practice: across the health professionals. 2nd edition, Chatswood, NSW: Elsevier.

Holloway KL, Smith KW and Wilberger JE (1996). Antimicrobial prophylaxis during clean neurosurgery: a large, multicentre study using cefuroxime. Clin. Ther. 18: 84-94.

Kourbeti IS, Vakis AF and Papadakis JA (2012). Infections in traumatic brain injury patients. Clin. Microb. Infect. 18: 359-364.

Kupronis B, Edwards J and Horan T (2004). Nosocomial infections in neurosurgical intensive care units in America. Am. J. Infect. Ctrl. 32. CDC Atlanta, Georgia.

Mewe R, Konig HJ and Karhoff HL (1991). Perioperative preventive use of antibiotics in neurosurgery. Experience with a fixed antibiotic combination of mezlocillin and oxacillin (optocillin). Neurochir (Stuttg). 34: 14-17.

Nejat F, Tajik P and El Khashab M (2008). A randomised trial of ceftriaxone versus trimethoprim-sulfamethoxazole to prevent ventriculoperitoneal shunt infection. J. Microb, Immun. Infect. 41: 112-117.

Parker S.L, Anderson WN and Lilienfield S (2011). Cerebrospinal shunt infection in patients receiving antibiotic impregnated versus standard shunts. J. Neurosurg: Paed. 8: 259-265.

Parker S.L, Farber H and Owoicho A (2011). Comparison of hospital cost and resource use associated with antibiotic impregnated versus standard shunt catheters. Clin. Neurosurg. 58: 122-125.

Pattavilakom A, Xenos C and Bradfield O (2007). Reduction in shunt infection using antibiotic impregnated CSF shunt catheters: an Australian prospective study. J. Clin. Neurosci. 14: 526-531.

Petignat C, Francioli P, and Harbarth S (2008). Cefuroxime prophylaxis is effective in noninstrumented spine surgery. A double blind placebo-controlled study. SPINE. 33:1919-1924.

Ratilal B, Costa J, and Sampaio C (2006). Antimicrobial prophylaxis for surgical introduction of intracranial ventricular shunts. Cochrane Database of Systematic Reviews [2006(3): CD 005365].

Ratilal B, Costa J, and Sampaio C (2008). Antimicrobial prophylaxis for surgical introduction of intracranial ventricular shunts: a systematic review. J .Neurosurg. Paed. 1: 48-56.

Ratilal B and Sampaio C (2011). Prophylactic antibiotics and anticonvulsants in neurosurgery. Adv. Tech. Std. Neurosurg. 36: 139-185.

Reider MJ, Frewen TC, and Del Maestro RF (1987). The effect of cephalothin prophylaxis on postoperative ventriculoperitoneal shunt infections. Can. Med. Assoc. J. 136: 935-838.

Rocca B, Mallet MN and Scemama F (1992). Perioperative remote infections in neurosurgery.Role of antimicrobial prophylaxis. La. Presse. Medicale. 21:2037-40.

Sackett DL (1997): Evidence based medicine. Seminars in Perinatology. 21: 3-5.

Schmidt K, Gjerris F and Osgaard O (1985). Antimicrobial prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 152 hydrocephalic patients. Neurosurg. 17:1-5.

Schunemann H, Brozek J, Guyatt G editors (2013). GRADE handbook for grading the quality of evidence and the strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from (Accessed 15/4/2015).

Sciubba D.M, Stuart R.M, and McGirt M.J. (2005). Effect of antibiotic impregnated shunt catheters in decreasing the incidence of shunt infection in the treatment of hydrocephalus. J. Neurosurg. Paed. 103: 131-136.

Shapiro M (1991). Prophylaxis in otaryngologic surgery and neurosurgery: a critical review. Rev. Infect. Dis. 13: S858-868.

Shapiro M, Wald U, and Simchen E (1986). Randomised clinical trial of intra-operative antimicrobial prophylaxis of infection after neurosurgical procedures. J. Hosp. Infect. 8: 283-295.

Tacconelli E, Cataldo MA, and Albanese A (2008). Vancomycin versus cefazolin prophylaxis for cerbrospinal shunt placement in a hospital with a high prevalence of meticillin-resistant Staphylococcus aureus. J. Hosp. Infect. 69: 337-344.

Van Ek B, Djikmans BA, Van Dulken H (1988). Antimicrobial prophylaxis in craniotomy: a prospective double- blind placebo-controlled study. Scand. J .Infect. Dis. 20: 633-639.

Van Ek B, Djikmans BA, and Van Dulken H (1991). Efficacy of cloxacillin prophylaxis in craniotomy: a one year follow up study. Scand. J. Infect. Dis. 23: 617-623.

Yamamoto M, Jimbo M, and Ide M (1996). Perioperative antimicrobial prophylaxis in neurosurgery: clinical trial of systemic flomoxef administration and saline containing gentamicin for irrigation. Neur. Medico- Chir. 36: 370-376.

Young RF and Lawner PM (1987). Perioperative antimicrobial prophylaxis for prevention of postoperative neurosurgical infections. A randomized clinical trial. J. Neurosurg. 66:701-5.

Zabramski JM, Whiting D and Darouiche RO (2003). Efficacy of antimicrobial -impregnated external ventricular drain catheters: a prospective, randomized controlled trial. J. Neurosurg. 98:725-30.

Zentner J, Gilsbach J, and Felder T (1995). Antimicrobial prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients. Neurosurg. Rev. 18:169-72.

Zhu XL, Wong WK and Yeung WM (2001). A randomized double blind comparison of Ampicillin/Sulbactam and ceftriaxone in the prevention of surgical-site infections after neurosurgery. Clin. Ther. 23:1281-91.

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