Surgical antibiotic prophylaxis and ventricular shunt surgical site infections
Authors: Koutsari Christina , Johnson Lia , LeBlanc Julie 
Published: January 2025

Abstract

Corresponding author: Christina Koutsari, Allina Health, Mail Route 10807, 2925 Chicago Avenue, Minneapolis, MN 55407, 507-261-0362, christina.koutsari@allina.com
Alternate corresponding author: Julie LeBlanc, Children’s Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404, 651-270-0196, julie.leblanc@childrensmn.org
Funding sources for abstract and associated work: Children’s Minnesota
No conflicts of interest.

Background
National guidelines recommend cefazolin for surgical prophylaxis of clean neurosurgical procedures. Addition of vancomycin is recommended if there is high-risk for MRSA infection. Non beta lactam antibiotics (e.g. vancomycin, clindamycin) are associated with higher rate of surgical site infections compared to beta lactams. The goal of this quality improvement project was to align Children’s Minnesota surgical prophylaxis recommendations for ventricular shunt procedures with recommendations from national guidelines.

Methods
We evaluated antibiotic selection, timing, duration, and surgical site infections (SSIs) in ventricular shunt procedures between 2013 and 2023. In May 2012, a ventricular shunt SSI prevention bundle was implemented that included vancomycin monotherapy as the drug of choice for surgical prophylaxis. In Q1 2020 onwards, cefazolin was considered the drug of choice with addition of vancomycin if presence of MRSA colonization or infection. Bundle adherence was assessed based on chart review by Infection Prevention and Control. Number audits per month varied with minimum random sample of five procedures per campus per month. Ventricular shunt SSIs were assessed based on Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) criteria.

Results
Percent adherence with appropriate antibiotic selection after transition to cefazolin was 85% to 95% and was lower compared to before transition to cefazolin (Figure 1). The lowest rate of adherence with antibiotic selection was in 2020 and was attributed primarily to concurrent use of cefazolin and vancomycin. Percent adherence with appropriate antibiotic timing was &gt;90% after transition to cefazolin and was higher than before transition to cefazolin. Overall rate of SSIs was 3.5 vs. 2.2 per 100 ventricular shunt procedures in 2013-2019 vs. 2020-2023, respectively (Table 1). There were lower proportions of SSIs due to MSSA and coagulase negative Staphylococcus (CoNS) in 2020-2023 (Figure 2). Ventricular shunt SSIs due to MRSA were low both before and after transition to cefazolin.

Conclusion
Transition to cefazolin prophylaxis for ventricular shunt procedures was associated with higher adherence with antibiotic timing but lower adherence with antibiotic selection. Transition to cefazolin was also associated with lower proportions of SSIs due to MSSA and CoNS, the most common SSI pathogens prior to transition to cefazolin. No increase in MRSA SSIs was observed. Longer surveillance is required to continue to assess adherence to the new antibiotic prophylaxis recommendations and its association with SSIs.

Figure 1
Table 1

Figure 2