Bone flap infections after craniotomy: a review of 63 cases and the implications for definitions, classification and surveillance methodologies.

BACKGROUND: Bone flap infections (BFIs) occur following neurosurgical procedures such as craniotomies. However, they are poorly defined and often not clearly differentiated from other surgical site infection in neurosurgery. AIM: To review data from a national adult neurosurgical centre to explore some clinical aspects to better inform definitions, classification and surveillance methodologies. METHODS: We retrospectively reviewed data on clinical samples sent for culture from patients with suspected BFI. We also accessed information recorded prospectively from national and local databases for evidence of BFI or related conditions based on terms used in surgical operative notes or discharge summaries and documented monomicrobial and polymicrobial infections related to craniotomy sites. FINDINGS: Between January 2016 and December 2020, we documented 63 patients with a mean age of 45 years (16-80). Craniectomy for infection of the skull was the most common terminology used to describe BFI in the coding used in a national database, 40/63 (63%), but other terms were used. A malignant neoplasm was the most common underlying condition necessitating craniectomy in 28/63 (44%) cases. Specimens submitted for microbiological investigation included 48/63 (76%) bone flaps, 38/63 (60%) fluid/pus, and 29/63 (46%) tissue. Fifty-eight (92%) patients had at least one culture-positive specimen; 32 (55%) were monomicrobial and 26 (45%) were polymicrobial. Gram-positive bacteria predominated and Staphylococcus aureus was the most common. CONCLUSION: Greater clarity on how to define BFI is required to enable better classification and the carrying out of appropriate surveillance. This will inform preventative strategies and more effective patient management.

Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit?

Background: In an era of increasing antimicrobial resistance, appropriate antimicrobials are essential to optimise patient outcomes. In 2017, antimicrobial use prevalence (AMU) on the two neurosurgical wards in our tertiary teaching hospital varied from 23% on ward A to 33% on ward B with 67% and 100% 'appropriate' prescriptions, respectively. In July 2018, a weekly antimicrobial stewardship multidisciplinary round led by a senior neurosurgery registrar commenced, attended by the antimicrobial stewardship team (AST). Research question: This report evaluates whether a multi-disciplinary approach on neurosurgical prescribing was beneficial, specifically in reducing AMU. Materials and methods: The following data was collected on AST rounds for 30 weeks in total from August 2018 to July 2019: number of patients on antimicrobials, appropriateness and stewardship actions. A questionnaire was distributed to neurosurgical doctors on two occasions to canvass opinions and attitudes on antimicrobial prescribing. Results: 1716 prescriptions were reviewed (mean 57.2 per week). Of these 321 (18.7%) included antimicrobial prescriptions; 200 on ward A (19.8%), and 121 on ward B (17%), representing a decrease in AMU from 2017. The majority of antimicrobial prescriptions, 271 (84.4%) were deemed appropriate. Stewardship actions were taken in 215 (67%) prescriptions.Fifteen questionnaires were completed by neurosurgical doctors. The majority, 87%, stated the AST round was helpful overall. 93% indicated that informal training on the AST round was a source of education in antibiotic prescribing. Discussion and conclusion: The weekly AST round provided a timely opportunity for multidisciplinary discussion, implementation of antimicrobial stewardship actions and opportunistic antimicrobial stewardship education.

Spontaneous Escherichia coli Meningitis and Pyogenic Ventriculitis in an Adult Receiving Anti-Tumour Necrosis Factor Alpha Therapy.

Presentation A 60-year-old male taking etanercept for ankylosing spondylitis was admitted to hospital with confusion and reduced level of consciousness over the preceding 24 hours. Diagnosis Magnetic Resonance Imaging (MRI) of his brain revealed pyogenic ventriculitis, and Escherichia coli was cultured from CSF. Treatment He required placement of an external ventricular drain and was treated with a prolonged course of intravenous ceftriaxone. Conclusion To our knowledge, this is the first reported case of spontaneous Gram-negative bacillary meningitis in a patient on anti-tumour necrosis factor (TNF)-alpha therapy, highlighting the risk of rare but serious infections associated with this class of medication.

Factors affecting caries levels amongst 5-year-old children in County Kerry, Ireland.

OBJECTIVE: To investigate the factors associated with high caries levels in 5-year-old children in the Kerry Community Care Area of the Southern Health Board in Ireland. DESIGN: Cross-sectional study. SETTING: County Kerry, Ireland in 1997. SUBJECTS: A random sample of 5-year-old children. METHOD: Six hundred and thirty-six 5-year-old children were examined for caries following WHO diagnostic criteria. Information on possible caries risk factors was collected by means of a parental questionnaire. RESULTS: Using multivariate logistic regression analysis the variables most significantly associated with the presence of caries were water fluoridation status, whether or not the child took the baby feeding bottle to bed, the age at which tooth brushing started and the number of sweet snacks and drinks taken in a day. While there was a wide variation in caries levels between nine geographic areas in Co. Kerry the only significant geographic variation found was between fluoridated and non-fluoridated areas. CONCLUSION: The prevalence of dental caries amongst 5-year-old children in Co. Kerry was highest in those residing in non-fluoridated communities, in those who took a baby feeding bottle to bed, in those who did not commence tooth brushing until after two years of age and in those who had sweet snacks or sweet drinks between meals three or more times per day.

Assessment of visual function in autistic children.

Children with autism demonstrate "atypical" gaze or social "looking" and frequently manifest such sterotypies as eye pressing, hand flicking, and light gazing. This study's purpose was to evaluate autistic children for visual dysfunction that may be related to the manifested visual signs and symptoms. Thirty-four autistic children, ages 2 to 11 years (median age = 7 years, 6 months) were evaluated for ocular alignment, refractive error, visual acuity, oculomotility skills, and stereopsis. None of the children manifested ocular disease, known seizure disorders, or dysmorphic features. Their developmental levels ranged from average intelligence to severely retarded. Binocular visual acuity was measured with the acuity card procedure. Monocular visual acuity was not obtained. Refractive errors ranged from -4.25 to +3.25 D; the median was plano with the near retinoscopy technique. Of the 34 children, 21% were strabismic at far and 18% were strabismic at near. Lang stereo testing was attempted on all children and completed on 17. Of the 17, all but 3 exhibited 550 sec arc. Only 14.7% of the children exhibited voluntary pursuit movements, and all the children demonstrated saccadic fixations. Thirty-one children had atypical optokinetic nystagmus (OKN) responses such as delayed onset, short duration, gaze avoidance, or stereotypic behavior. Repeated testing revealed consistent visual responses on OKN and visual acuity. Given these findings, research with this population should be pursued further.