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Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1737-1742

Survey of Prophylactic use of Antibiotics among Indian Neurosurgeons


1 Department of Neurosurgery, Wockhardt Hospital, Mumbai, Maharashtra, India
2 Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission12-Apr-2020
Date of Decision04-May-2020
Date of Acceptance14-Jul-2020
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Vedantam Rajshekhar
Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333485

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 » Abstract 


Background: Despite recommendations and guidelines, surgical antibiotic prophylaxis protocol for neurosurgical cases is not uniformly followed.
Objective: To report trends in the use of prophylactic antibiotics by Indian neurosurgeons for non-trauma neurosurgical cases.
Materials and Methods: An email survey consisting of 17 questions was sent in 2018 to 2,175 surgical members with a registered email in the Neurological Society of India (NSI) registry. Three reminders were sent at 3-month intervals. The results were analyzed for the number, type, and duration of antibiotic use for different surgical procedures. The differences in the antibiotic policy in different practice settings were also studied.
Results: The response rate was less than 5% (103 responses). Almost all (98.1%) surgeons used prophylactic antibiotics. A single antibiotic was most used for cranial surgeries (85%) and least for spine surgeries with instrumentation (64%) (P = 0.001). One dose or 1 day of antibiotics was used by the least number of responders (29%) for spinal instrumentation surgeries and the most responders (66.7%) for spinal surgery without instrumentation (P < 0.0001). Surgeons working in corporate teaching hospitals or non-teaching hospitals were more likely to use antibiotics for longer duration than surgeons working in government/trust teaching hospitals.
Conclusions: Substantial numbers of surgeons use prophylactic antibiotics for more than 1 day with a higher proportion of surgeons working in corporate teaching and non-teaching hospitals pursuing such a policy.


Keywords: Antibiotic prophylaxis, brain surgery, spine surgery, surgical site infections, survey
Key Message: There is a need for rationalizing the number and duration of prophylactic antibiotic therapy for different neurosurgical procedures. There is a significant variation in the prophylactic antibiotic policy between different practice settings in India.


How to cite this article:
Turel MK, Meshram B, Rajshekhar V. Survey of Prophylactic use of Antibiotics among Indian Neurosurgeons. Neurol India 2021;69:1737-42

How to cite this URL:
Turel MK, Meshram B, Rajshekhar V. Survey of Prophylactic use of Antibiotics among Indian Neurosurgeons. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1737-42. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1737/333485




Use of prophylactic antibiotics for prevention of infection in elective neurosurgery has been a contentious issue but several published series have supported their use.[1],[2],[3],[4],[5] The World Health Organization (WHO) provides recommendations on the administration of surgical antibiotic prophylaxis prior to surgical incision when indicated, depending on the type of operation and its timing and duration.[6] WHO has also incorporated its use in the surgical safety checklist for all surgical cases.[7]

Despite available guidelines there is a wide variation in the administration, use and duration of surgical antibiotic prophylaxis (SAP) in neurosurgery.[2] To better understand the trends in the use of SAP across various practice models and institutions in India, we gathered information pertaining to their use in commonly performed clean, elective, non-trauma cranial and spinal procedures. To our knowledge, this is the first such survey conducted amongst Indian neurosurgeons.


 » Materials and Methods Top


Questionnaire

A questionnaire [Supplementary file 1] was formulated on Survey Monkey™ (www.surverymonkey.com), which included 17 questions regarding the use of antibiotic prophylaxis in various neurosurgical procedures. The questionnaire was anonymous and included questions on if SAP was routinely used in their practice, the class and duration of antibiotics used for various brain and spine procedures and the employment of a regular audit on SSIs.

This questionnaire was first sent in April 2018, via e-mail to 2,175 neurosurgeons across India who had a registered email address with the Neurological society of India. Three reminders were sent at 3 monthly intervals, the final reminder being sent in April 2019. The survey was closed in July 2019. The responses were charted in an Excel database (Microsoft Inc, Seattle, USA) and analyzed.

Types of surgery

Surgical types were categorized as: cranial surgery, trans-sphenoidal surgery, spine surgery without instrumentation, spine surgery with instrumentation, and ventriculo-peritoneal (VP) shunt surgery.

Practice types

Hospitals were categorized as teaching hospitals when they had a neurosurgical training program (M.Ch. or Diplomate of the National Board). Surgeons practice locations (hospitals) were categorized as following: government teaching, trust teaching, corporate teaching, corporate or trust non-teaching and other private practice. For comparison, government teaching and trust teaching hospitals were considered together and all other practice locations as the other group.

Statistical methods

Significance in differences in proportions was calculated using Fisher's exact test or Chi-square test. A P value of < 0.05 was considered as significant.


 » Results Top


Response rate

Of the 2,175 e-mails sent, we received 103 (4.74%) responses after three reminders. Approximately 90% of the responses were obtained after the first mailing, 9% after the second mailing, and only 1% after the last mailing. Not all responders answered all questions and hence there were different denominators for the different questions.

Geographical location

Ninety-two responders mentioned the location of their practice. The regional distribution of the responders was as follows: south 55 (59.8%), north 12 (13%), west 12 (13%), east 6 (6%), central 6 (6%), and north-east 1 (1%).

Practice type

Forty-three percent of the surgeons worked in a government or not-for-profit trust teaching hospital, 25.1% worked in a corporate for profit teaching hospital, 27.5% worked in a non-teaching corporate/private hospital, and the rest (3.9%) in a non-teaching government or not-for-profit trust hospital. The antibiotic policy was determined by the individual surgeon in 24.8% of the cases, by the surgical unit in in 32.7% and by the Institution's infection policy-making authority in 42.6%. So in most instances (>75%), it is either the unit or hospital policy that determines the SAP.

Annual number of surgeries

All the responders' departments performed substantial numbers of cranial and spinal surgeries. Fifty-one (50%) of the responders performed ≤ 500 surgeries in the last 1 year, 32 (31.4%) performed between 501 and 1,000 surgeries, while 6 (5.9%) performed 1,001 to 1,500 surgeries in the last 1 year. Thirteen (12.7%) responders belonged to institutes where > 1,500 surgeries were done in the last 1 year.

Surgical site cleaning solution

Out of 102 responders to the query on cleaning solution used, 46 (45.1%) surgeons preferred povidone iodine and 41 (40.2%) used a combination of povidone iodine and chlorhexidine. The remaining 15 (14.7%) surgeons used povidone, Sterillium (Hartmann AG, Germany), spirit, povidone scrub, tincture of iodine, alone or in combination.

Number of antibiotics used

An overwhelming number of neurosurgeons used a single antibiotic for cranial surgery (85%), spine surgery without instrumentation (82%) [Table 1], VP shunt surgery (72%), trans-sphenoidal surgery, (65%) and spine with instrumentation (64%) (Chi-square statistic 18.4496, P = 0.001). Around 30% of neurosurgeons preferred to use dual antibiotics in trans-sphenoidal, spinal instrumentation cases, and VP shunt surgery. Only 5–7% of responders preferred > 2 antibiotics and this preference was reserved for trans-sphenoidal and spinal instrumentation cases.
Table 1: Number of antibiotics used for surgical prophylaxis

Click here to view


Family of antibiotics used

Considering all surgeries, cephalosporins (first to third generation) were the predominant antibiotic family that was used as SAP [Table 2]. Use of cephalosporins (of different generations), either alone or in combination with other antibiotics, ranged from 89.8% in spinal instrumentation surgeries to 97% in cranial surgeries. Of the cephalosporins, third-generation cephalosporins (cefotaxime, ceftriaxone, ceftazidime and cefixime) were the most commonly used antibiotics. Their use as monotherapy ranged from 33% for spinal instrumentation surgeries to 54.5% for cranial surgery. In combination with another antibiotic, third-generation cephalosporins use ranged from 13.1% in cranial surgeries to 27.8% in spinal instrumentation surgeries.
Table 2: Family of antibiotic used for surgical prophylaxis

Click here to view


Specific antibiotics used [Supplementary file 1]

When monotherapy was used as SAP, ceftriaxone was the commonest antibiotic used (~50%), followed by cefuroxime and cefazoline, across the entire spectrum of cases.

Interestingly, three antibiotics were used as prophylaxis most often in patients undergoing trans-sphenoidal surgeries (6 responders) and spinal instrumentation surgeries (5 responders). Only one surgeon used three antibiotics for cranial cases and another for VP shunt surgery.

Four antibiotics were only used by one surgeon for trans-sphenoidal surgery.

Duration of antibiotic use

One dose or 1 day of SAP was used by the least number of responders (29%) for spinal instrumentation surgeries and the most responders for spinal surgery without instrumentation (66.7%) (Chi-square statistic 27.7672, P = .000014). For other surgeries, the number was within this range [Table 3].
Table 3: Duration of surgical antibiotic prophylaxis

Click here to view


Over 70% of surgeons use SAP for <3 days except for spinal instrumentation surgeries where slightly <65% used SAP for <3 days. SAP for >3 days was used by the most number of responders (36.1%) for spinal instrumentation surgeries followed by VP shunt surgeries (27.2% responders) and trans-sphenoidal surgeries (24.7% responders).

Only 2.3% of surgeons reported >7 days of prophylactic antibiotics use for spinal instrumentation cases.

Influence of practice setting

The proportion of surgeons using a single antibiotic for different surgical procedures was higher in the government/trust teaching hospital setting when compared to those working in corporate teaching/non-teaching hospitals. However, these differences were not statistically significant [Table 4].
Table 4: Prophylactic antibiotic use in different practice settings

Click here to view


A significantly higher proportion of surgeons working in corporate teaching/non-teaching hospitals used antibiotics for ≥1 day for cranial surgeries (P = 0.04), spinal surgeries without instrumentation (P = 0.006), and VP shunt surgery (P = 0.04). For trans-sphenoidal surgery also there was a similar trend but the difference did not reach statistical significance (P = 0.06).

There was no difference in the antibiotic policy between surgeons who practiced in centers where ≤ 500 cases were done per year and those who practiced in centers where > 500 cases were done per year.

Infection audit

Only 61 (59.8%) of the 102 responders reported that an infection audit is performed in their institute. Of these 61 responders, 57 reported a SSI rate in the range of 0.06–6% (mean, 2.5% in the last two years.

Infection related mortality

Out of 101 surgeons, only 16 (15.8%) reported deaths due to SSI in the last one year. Of them, 12 (11.8%) mentioned <5 deaths at their institute and one (0.9%) reported 6–10 deaths. Three surgeons (2.9%) reported deaths but could not provide a specific number.


 » Discussion Top


Surgical site skin preparation

Based on several Randomized Control Trials (RCTs) the WHO recommends alcohol-based antiseptic solutions that are based on chlorhexidine gluconate for surgical site skin preparation.[6] A significant reduction of the SSI risk was shown with the use of alcohol-based chlorhexidine gluconate compared with either aqueous povidone-iodine or povidone-iodine in alcohol-based solutions. In our survery, povidone iodine as a preoperative cleaning solution was used by 45% of surgeons, while a chlorhexidine based solution was used only by 9.8% and a combination of povidone and chlorhexidine based solution by 40.2%.

Recommended prophylactic antibiotics

The majority of studies on SAP report a protocol of a single dose of antimicrobials.[8] Use of single-dose antimicrobial prophylaxis given within 60 mi before the surgical incision in patients undergoing neurosurgery is generally recommended.[9] However, when deciding on the drug for SAP for an individual patient, the patient's comorbidities, allergies, length, and complexity of the procedure and issues of antibiotic resistance should also be considered.[3],[4] Our survey results revealed that <50% of surgeons used SAP for <1 day for cranial surgeries and only about 25% gave a single dose of antibiotics.

Currently, a single dose of cefazolin (not followed by further antibiotic administration) is recommended by the AAHP/IDSA/SIS/SHEA (American Society of Health System Pharmacists, the Infection Disease Society of America, Surgical Infection Society, the Society for Healthcare Epidemiology of America) for patients undergoing clean neurosurgical procedures.[9] However in our survey, the use of a first-generation cephalosporin (either alone or in combination) was reported by only 5.2–11.1% of surgeons for different neurosurgical procedures.

Liu et al.,[10] studied the role of third-generation cephalosporins which included five randomized controlled trials (RCTs) enrolling a total of 2,209 patients. The study failed to show superiority of third-generation antibiotic prophylaxis over conventional regimens (broad spectrum penicillins, first/second-generation cephalosproins, aminoglycosides, and glycopeptides regarding both incisional and organ related SSI in neurosurgery. Interestingly, our survey showed that >60% of the responders used a third-generation cephalosporin, either alone or in combination, for different neurosurgical procedures.

The use of SAP should be weighed against the costs and potential side effects, including allergic reactions, Clostridium difficile enterocolitis, and spread of antimicrobial resistance.[11] Hence, use of the lowest generation of antibiotics and for the shortest duration of time would be the ideal protocol for SAP.

Surveys for SAP in neurosurgery

Response to surveys in neurosurgery have generally been less than satisfactory.[12],[13],[14] Web-based surveys in particular have a low response rate.[15] Our response rate was 4.75%.

Matsuda et al.[13] conducted a survey on SAP in Japan and concluded that several practices related to SAP were not in keeping with the WHO guidelines, especially with regard to the duration of antibiotic use. Their survey showed that 80% of Japanese neurosurgeons administered antibiotics beyond the recommended 24 h.

In another survey conducted by Little and White[16] in the United States on the use of SAP in trans-sphenoidal surgeries for pituitary lesions, 76% used only one class of antibiotics, but 22% used two antibiotics and 2% used three antibiotics. We noted similar trends in our survey. In our survey, 35% of surgeons used >1 antibiotic and only 40.4% of surgeons used antibiotics for ≤1 day for trans-sphenoidal surgeries. Fang et al.[17] surveyed the use of SAP for anterior skullbase surgery. Most surgeons (95%) gave SAP. Most used a first or second-generation cephalosporin (55.5%) while a third to fifth-generation cephalosporin was also used by a large number of surgeons (43.4%).

A recent international consensus document on spine surgery recommended that the optimal prophylactic antibiotic for uncomplicated spine surgery is a first-generation or second-generation cephalosporin given intravenously within 60 min of the initial incision, a single preoperative dose being sufficient. We noted that while 81.8% of surgeons administered only one antibiotic for spine surgeries without instrumentation, this percentage dropped to 64% for instrumented spine surgeries. Also the use of SAP beyond 1 day was reported by 71% of surgeons for instrumented spine surgeries as opposed to only 33.3% for non-instrumented spine surgeries.

SAP in different practice settings

Little and White found no significant relationship between antibiotic choice, duration, or incidence of meningitis and practice setting or duration of practice when they surveyed for the use of SAP for trans-sphenoidal surgery.[16]

A study on SAP from Iran evaluated SAP policies in private and public hospital settings across various specialties including neurosurgery.[18] They found that approximately 90% of patients received inappropriate surgical prophylaxis in private hospitals in the form of prolonged duration of antibiotics administration beyond that recommended by guidelines. Only 20% of patients in private hospitals received a single-dose antibiotic as SAP.

Indian publications on surgical antibiotic prophylaxis

Moorthy et al.[19] from Vellore, used a conservative SAP regime of using either a 1-day course of intravenous chloramphenicol or a single dose of ceftriaxone for cranial cases that resulted in bacterial meningitis in 0.8% of their 3401 craniotomies restrospective analyzed. When they added a staphylococal decolonization regime to their protocol they found a reduction in both bacterial and aseptic meningitis rates, the latter being statistically significant.[20] Sharma et al.[21] from Delhi concluded that using a risk-stratified protocol of perioperative antibiotic prophylaxis helps to significantly decrease not only postoperative bacterial meningitis rates, but also infections at other systemic sites such as the respiratory and urinary tracts. Srinivas et al.[22],[23] from Bangalore reported an incidence of bacterial meningitis rate of 2.2%in 18,092 patients. Cefotaxime alone or in combination with amikacin and metronidazole were used for different categories of patients, the duration ranging from 24 h to 72 h.

Almost all our survey respondents had different SAP protocols for different surgeries. In other words, neurosurgeons in India use some form of risk stratification when deciding on the SAP for different surgeries.

Limitations

The obvious limitation of our study is the poor response rate to the survey, which limits our ability to generalize the findings to the practice of neurosurgery in the country as a whole. Due to the anonymous nature of the survey, it was difficult to determine if more than one person from the same department replied which could result in a potential skewing of results. Questions on preoperative preparation of the patient, which may impact on SSI, such as hair removal, hair wash prior to surgery, staphylococcal decolonization, and nutritional optimization were not discussed in this study. The timing of antibiotic administration in relation to the incision was also not queried. Finally, we did not seek justification of the prophylactic antibiotic policy and are therefore unable to understand the policies for different surgeries in different centers. However, we wanted to keep the survey as brief as possible with a focus on the class and duration of antibiotics used in different types of neurosurgical cases.


 » Conclusions Top


Almost all neurosurgeons in India administer SAP. A significant proportion of surgeons prescribe SAP for more than 1 day. Surgeons perceive patients undergoing trans-sphenoidal surgeries, instrumented spine surgeries, and VP shunt surgeries to be most at risk for SSI. Hence, they tend to prescribe multiple antibiotics for longer duration to these patients. Surgeons practicing in corporate teaching and non-teaching hospitals are more likely to administer SAP for more than 1 day as compared to their peers practicing in government/trust teaching hospitals. The reasons for this are unclear.

Acknowledgements

We thank all the neurosurgeons who participated in the survey. We are grateful to Dr. Ranjith K Moorthy for his help with the questionnaire.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


 » Supplementary file 1 Top


Antibiotic prophylaxis in elective (non-trauma) neurosurgery (this survey applies to practices at least for the last 2 year)

1. Do you use antibiotic prophylaxis for elective surgery (cranial and spinal)?

Yes

No

If no, proceed to Question 9

2. If yes, is the selection of antibiotics based on a written protocol?

Yes

No

3. What dictates the antibiotic policy?

Individual surgeon

Unit Policy

Decided by the institution's infection policy making authority.

3. Please specify the antibiotics used (generic name only) for the following cases:

Cranial (open/endoscopic/DBS) surgery

Transsphenoidal surgery

Spinal surgery without instrumentation

Spinal Surgery with instrumentation

VP shunts

4. What is the duration of prophylactic antibiotic therapy for cranial (open/endoscopic/DBS) surgery?

Single Dose only

More than 1 dose but less than a day

1–3 days

3–5 days

5–7 days

>7 days

5. What is the duration of prophylactic antibiotic therapy for trans-sphenoidal surgery?

Single Dose only

More than 1 dose but less than a day

1–3 days

3–5 days

5–7 days

>7 days

6. What is the duration of prophylactic antibiotic therapy for spinal surgery without instrumentation?

Single Dose only

More than 1 dose but less than a day

1–3 days

3–5 days

5–7 days

>7 days

7. What is the duration of prophylactic antibiotic therapy for spinal surgery with instrumentation?

Single Dose only

More than 1 dose but less than a day

1–3 days

3–5 days

5–7 days

>7 days

8. What is the duration of prophylactic antibiotic therapy VP shunts?

Single Dose

More than 1 dose but less than a day

1–3 days

3–5 days

5–7 days

>7 days

9. Do you or your unit have an infection audit on a monthly or annual basis?

Yes

No

10. If yes, please mention the yearly surgical site infection (SSI) rate for the last 2 years. Do not include exclusive urinary, respiratory or other site infections. If patient has SSI along with other site infections, please include.

Year 1

Year 2

11. If no, then please provide an estimate of SSI for the last 2 years:

0–2%

2–4%

4–6%

>6%

Don't know

12. What solution do you use for pre-operative surgical site cleaning:

Povidone Iodine based solution

Chlorhexidine based solution

Combination of povidone and chlorhexidine based solution

Other, specify

13. In the last 1 year, has any patient died due to a Surgical Site Infection (SSI)?

Yes

No

14. If yes, how many patients have died?

<5

6–10

11–15

>15

Don't know

15. Where do you primarily work?

Teaching hospital (government or trust not for profit)

Teaching hospital (corporate for profit)

Non-teaching government or trust not for profit

Non-teaching corporate/private hospital

16. How many elective cranial/spinal cases did you/your unit operate in the last 1 year.

<500

501–1000

1001–1500

>1500

17. Any other information with respect to SSI that you would like to provide?





 
 » References Top

1.
Cao Y, Pu K, Li G, Yan X, Ma Y, Xue K, et al. The role of antibiotic prophylaxis in clean neurosurgery. World Neurosurg 2017;100:305-10.  Back to cited text no. 1
    
2.
Moldovan ID, Agbi C, Kilty S, Alkherayf F. A systematic review of prophylactic antibiotic use in endoscopic endonasal transsphenoidal surgery for pituitary lesions. World Neurosurg 2019;128:408-14.  Back to cited text no. 2
    
3.
Watters WC, Baisden J, Bono CM, Heggeness MH, Resnick DK, Shaffer WO, et al. Antibiotic prophylaxis in spine surgery: An evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 2009;9:142-6.  Back to cited text no. 3
    
4.
Shaffer WO, Baisden JL, Fernand R, Matz PG; North American Spine Society. An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery. Spine J 2013;13:1387-92.  Back to cited text no. 4
    
5.
Dimovska-Gavrilovska A, Chaparoski A, Gavrilovski A, Milenkovikj Z. The importance of perioperative prophylaxis with cefuroxime or ceftriaxone in the surgical site infections prevention after cranial and spinal neurosurgical procedures. Pril 2017;38:85-97.  Back to cited text no. 5
    
6.
Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: An evidence-based global perspective. Lancet Infect Dis 2016;16:e276-87.  Back to cited text no. 6
    
7.
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.  Back to cited text no. 7
    
8.
Liu W, Ni M, Zhang Y, Groen RJM. Antibiotic prophylaxis in craniotomy: A review. Neurosurg Rev 2014;37:407-14.  Back to cited text no. 8
    
9.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013;14:73-156.  Back to cited text no. 9
    
10.
Liu W, Neidert MC, Groen RJM, Woernle CM, Grundmann H. Third-generation cephalosporins as antibiotic prophylaxis in neurosurgery: What's the evidence? Clin Neurol Neurosurg 2014;116:13-9.  Back to cited text no. 10
    
11.
Savitz SI, Rivlin MM, Savitz MH. The ethics of prophylactic antibiotics for neurosurgical procedures. J Med Ethics 2002;28:358-63.  Back to cited text no. 11
    
12.
Davis MC, Rocque BG, Singhal A, Ridder T, Pattisapu JV, Johnston JM. State of global pediatric neurosurgery outreach: Survey by the International Education Subcommittee. J Neurosurg Pediatr 2017;20:204-10.  Back to cited text no. 12
    
13.
Matsuda S, Ikawa F, Ohba H, Yoshiyama M, Hidaka T, Kurisu K, et al. Questionnaire survey regarding prevention of surgical site infection after neurosurgery in Japan: Focus on perioperative management and administration of surgical antibiotic prophylaxis. Neurol Med Chir (Tokyo) 2019;59:197-203.  Back to cited text no. 13
    
14.
Shakir HJ, McPheeters MJ, Shallwani H, Pittari JE, Reynolds RM. The prevalence of burnout among US neurosurgery residents. Neurosurgery 2018;83:582-90.  Back to cited text no. 14
    
15.
Dykema J, Jones NR, Piché T, Stevenson J. Surveying clinicians by web: Current issues in design and administration. Eval Health Prof 2013;36:352-81.  Back to cited text no. 15
    
16.
Little AS, White WL. Prophylactic antibiotic trends in transsphenoidal surgery for pituitary lesions. Pituitary 2011;14:99-104.  Back to cited text no. 16
    
17.
Fang CH, Hawn VS, Agarwal V, Moskowitz HS, Kshettry VR, McKean EL, et al. Antibiotic prophylaxis in anterior skull-base surgery: A survey of the North American Skull Base Society. Int Forum Allergy Rhinol 2019;9:1196-204.  Back to cited text no. 17
    
18.
Mahdaviazad H, Masoompour SM, Askarian M. Iranian surgeons' compliance with the American Society of Health-System Pharmacists guidelines: Antibiotic prophylaxis in private versus teaching hospitals in Shiraz, Iran. J Infect Public Health 2011;4:253-9.  Back to cited text no. 18
    
19.
Moorthy RK, Sarkar H, Rajshekhar V. Conservative antibiotic policy in patients undergoing non-trauma cranial surgery does not result in higher rates of postoperative meningitis: An audit of nine years of narrow-spectrum prophylaxis. Br J Neurosurg 2013;27:497-502.  Back to cited text no. 19
    
20.
Gupta A, Nair RR, Moorthy RK, Rajshekhar V. Effect of staphylococcal decolonization regimen and change in antibiotic prophylaxis regimen on incidence of postcraniotomy aseptic meningitis. World Neurosurg 2018;119:e534-40.  Back to cited text no. 20
    
21.
Sharma MS, Vohra A, Thomas P, Kapil A, Suri A, Chandra PS, et al. Effect of risk-stratified, protocol-based perioperative chemoprophylaxis on nosocomial infection rates in a series of 31 927 consecutive neurosurgical procedures (1994-2006). Neurosurgery 2009;64:1123-30.  Back to cited text no. 21
    
22.
Srinivas D, Veena Kumari HB, Somanna S, Bhagavatula I, Anandappa CB. The incidence of postoperative meningitis in neurosurgery: An institutional experience. Neurol India 2011;59:195-8.  Back to cited text no. 22
[PUBMED]  [Full text]  
23.
Behari S. Post-craniotomy Meningitis. Neurol India 2011;59:154-5.  Back to cited text no. 23
[PUBMED]  [Full text]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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