Extended sequential intravenous and oral antimicrobial therapy improves cure rate in postoperative intracranial neurosurgical infections. A Spanish multicenter retrospective study

Extended sequential intravenous and oral antimicrobial therapy improves cure rate in postoperative intracranial neurosurgical infections. 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A Spanish multicenter retrospective study Víctor Asensi, C. Vázquez, S. Suárez-Díaz, E. Asensi-Díaz, N. Carrasco-Antón, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4946614/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Nov, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted 4 You are reading this latest preprint version Abstract Background Postoperative intracranial neurosurgical infections (PINI) complicate < 5% neurosurgeries. Scarce attention was dedicated to the extension and characteristics of its antimicrobial management considering their high morbidity, not negligible mortality, delayed hospital stay and increased healthcare costs. Methods We analyzed retrospectively (2014–2023) 162 PINI from eight Spanish third-level academic hospitals. Results Elective clean craniotomies after tumor or vascular causes were the leading procedures. Epidural abscess (24.7%), scalp infections (19.8%), postsurgical meningitis (16.7%) and cranioplasty infections (16.7%) were the most frequent PINI. Staphylococcus spp (43.9%) and Gram negative bacteria (38.6%) were the predominant isolates. Overall 85.2% patients underwent pus drainage, mostly by craniotomy (40.3%). Interestingly 34% were already receiving antibiotics for extracranial infections before developing PINI while 16.8% did not receive pre-operative antibiotic prophylaxis. In total 77.2% patients started a combined intravenous (IV) antimicrobial therapy, of which 85.2% switched after 5 days to a second-line IV antibiotic regimen, in 41.3% cases combined, after pus culture results, for a median of 21 days. Overall 61.1% patients continued on oral antimicrobials after hospital discharge, 30.3% as a combined regimen, for a median of 42 days. Complete cure was obtained in 81.5% cases, while 11.1% relapsed, 7.4% failed to cure and 6.8% died after PINI complications. In the multivariate analysis oral antimicrobial therapy after hospital discharge (p = 0.001) was significantly associated with PINI cure with a marginal positive effect on survival (p = 0.066) . Conclusions We conclude that an extended 6 weeks sequential IV and oral antimicrobial therapy in addition to neurosurgical correction increases PINI cure rate and might improve survival Clinical Trial Number: not applicable neurosurgery intracranial infections antimicrobial therapy cure mortality Background Postoperative intracranial neurosurgical infections (PINI) complicate < 5% of all neurosurgeries [ 1 – 14 ]., with lower infection rates reported in American series [ 5 ]. Extensive consideration has been paid so far to infections of other neurosurgical procedures such as external and internal cerebrospinal fluid (CSF) shunts and other implantable neural devices, mostly to CSF shunts ventriculitis [ 13 – 14 ]. However scarce attention has been dedicated to PINI, with efforts mainly focused on PINI risk factors but not on their treatment. This is especially surprising considering that PINI have a high morbidity, not negligible mortality, generate delayed hospital stays and increase greatly healthcare costs. PINI treatment necessitates in most of the cases a second neurosurgical intervention or even more to achieve cure. In addition, PINI therapy requires specific antimicrobials, used in high doses, able to cross the blood-brain barrier, with activity again methicillin-resistant staphylococci in many cases, and not exempt of side effects. Furthermore, PINI antimicrobials need to be administer intravenously (IV) several times a day for several weeks through a central catheter complicating nursing work. Frequently used antimicrobial guidelines are not explicit for PINI regarding the type of antibiotic to be used, alone or in combination, its administration route, switching time from IV to oral, and total duration of therapy [ 13 – 15 ]. For all these reasons we underwent this retrospective study on PINI focusing especially on the characteristics and duration of their antimicrobial management and their influence on cure and mortality outcomes. Patients and Methods Inclusion criteria Patients with 18 years or older diagnosed with PINI admitted to the Neurosurgery wards of Hospital Universitario Central de Asturias (HUCA), Oviedo, Hospital Universitario Fundación Jiménez Diaz, Madrid, Hospital 12 de Octubre, Madrid, Complejo Universitario de León, Hospital Universitario de Toledo, Hospital Universitario Germans Trias i Pujol, Badalona, Hospital Clínico Universitario de Valladolid and Hospital Vall d´Hebron; Barcelona, all in Spain, between May 1st 2014 and May 15th 2023 were included in the study. The diagnosis of PINI was primarily based on history, physical examination, microbiological, neuroimaging diagnostic procedures (head CT and/or MRI), and surgical findings at the operation room. The patients were followed a median of 9 months after hospital discharge by both a neurosurgeon and an Infectious Diseases (ID) consultant at each of the participant hospitals. The response to treatment was evaluated by the neurosurgeon in charge of the patient, based on clinical and neuroimaging findings and confirmed by the ID consultant PINI. cure implied absence of physical and neuroimaging signs of infection and lack of relapses or hospital re-admissions for neurosurgical infectious reasons during the follow-up. PINI relapse implied failure to cure, or initial response but relapse within 9 months of hospital discharge. Exclusion criteria Patients younger than 18 years, those with CNS infections due to external and internal (ventriculoperitoneal and ventroculoatrial) CSF shunts and to neurostimulators and those with spinal infections were excluded . Data collecting Many demographic, epidemiological, topographic, microbiological, clinical, laboratory, imaging, prognostic, hospitalization, and therapeutic (both surgical and antibiotic) data were collected and analyzed according to the PINI response to surgical and antimicrobial therapy. Regarding the diverse PINI, positive cultures obtained from blood, CSF, operation room drained pus collections and infected neurosurgical wounds exudates were considered. Statistical analysis Descriptive statistics was reported as median with interquartile range (IQR) for continuous variables and absolute numbers with percentages for categorical variables. Univariable and multivariable logistic regression and Cox proportional hazard models were employed to assess the effect of the variables of interest on PINI cure and mortality, respectively. The referring hospital was included in each model as a cluster to take into account that patients coming from the same hospital are more similar to each other. To avoid overfitting, variables included in the multivariable models were identified by performing a backward selection based on the Akaike Information Criterion (BIC). Results of logistic regression models were reported as Odds Ratio (OR) with its 95% confidence interval (95%CI) and p-value, while results of Cox regression models were reported as Hazard Ratio (HR) with its 95% confidence interval (CI) and p-value. The analyses were performed using R software (version 4.3.2). R Core Team (2023). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. Results Demographic characteristics of patients with PINI and predisposing factors leading to these infections The characteristics of the patients regarding gender, age and predisposing factors for PINI are presented in Table 1 Table 1 Demography, and predisposing factors to postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Demography - Gender Male 86 (53.1%) Female 76 (46.9%) - Age years 57.4 (47.2–69.0) Predisposing factors - Diabetes Yes 23 (14.2%) No 139 (85.8%) - Past or present smoking Yes 42 (25,9%) No 120 (74.1%) - Alcohol abuse Yes 15 (9.3%) No 147 (90.7%) -Previous extracranial infection Yes 31 (19.1%) No 131 (80.9%) - Immunodepression Yes 30 (18.5%) No 132 (81.5%) n = 30 - Cancer Yes 4(13.3%) No 26 (86.7%) …….Steroids therapy Yes 1 (3.3%) No 29 (96.7) Other immunosuppressive therapy Yes 2 (7.1%) No 28 (93.3%) Other immunosuppression causes Yes 23 (76.7%) No 7 (23.3%) Comorbidities Yes 40 (24.7%) No 122 (75.3%) ICU stay before neurosurgery Yes 39 (24.1%) No 123 (75.9%) ICU stay before neurosurgery days 0 (0-0.3) Values are expressed as median (IQ range) or absolute number (%). . Interestingly, one fifth had a previous extracranial infection when the PINI was diagnosed. Overall 18.5% had an immunodepression and one quarter carried other comorbidities that could facilitate PINI. Although one quarter of the patients were admitted to the ICU before neurosurgery their ICU stay was so short that did not contribute to PINI. Neurosurgery-related parameters of PINI The characteristics of neurosurgical procedures leading to PINI are presented in Table 2 . Table 2 Neurosurgery-related parameters of postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Surgery timing Urgent 50 (30.9%) Elective 112 (69.1%) - Surgery type Clean 124 (76.5%) Clean-contaminated 25 (15.4%) Contaminated 8 (4.9%) Dirty 5 (3.1%) Neurosurgery category Craniotomy 114 (70.4%) Craniectomy 15 (9.3%) Cranioplasty 29 (17.9%) Other 4 (2.5%) Surgery cause Vascular 35 (21.6%) Tumor 74 (45.7%) Trauma 25 (15.4%) Infection 8 (4.9%) Other 20 (12.3%) Surgery duration hours 3.0 (2.0–5.0) GCS at surgery 15.0 (15.0–15.0) Postsurgical CSF leakage Yes 33 (20.4%) No 129 (79.6%) Values are expressed as median (IQ range) or absolute number (%). GCS = Glasgow Coma Scale ; CSF = cerebrospinal fluid Two-thirds of the patients underwent elective, mostly clean, neurosurgery. Craniotomy was the predominant surgical procedure. The cause of neurosurgery was tumor in almost half of the patients followed by a vascular reason. Patients had a full Glasgow Coma Scale (GCS) score when entering the operating room. Surgery lasted a median of 3 hours .The main post-surgical complication was a cerebrospinal fluid (CSF) leakage in one fifth of the cases, enhancing post-surgical meningitis. PINI type, location and microbiology PINI type, location and microbiology of the drained pus, blood and CSF samples are shown in Table 3 Table 3 Type, location and microbiology of postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Infection type a Scalp Infection 32 (19.8%) Cranioplasty infection 27 (16.7%) Skull osteomyelitis 15 (9.3%) Epidural abscess 40 (24.7%) Subdural abscess 17 (10.5%) Intraparenchymal brain abscess 5 (3.1%) Meningitis 27 (16.7%) Other infections 11 (6.8%) Infection location a Frontal 47 (29.0%) Right parieto-temporal 44 (27.2%) Left parieto-temporal 32 (19.8%) Occipital 13 (8.0%) Not focalized 30 (18.5%) Cultured pus samples Yes 159 (98.1%) No 3 (1.9%) Culture positive pus samples Yes 132 (83.0%) No 27 (17.0%) Pus identified pathogens b Single pathogens Staphylococcus spp 58 (43.9%) Streptococcus spp 2 (1.5%) Gram negative bacteria 51 (38.6%) Other aerobic bacteria 4 (3.0%) Polimicrobial aerobes 19 (14.4%) Anaerobes c 20 (15.2%) Blood cultures Not drawn 91 (56.2%) Positive 11 (6.8%) Negative 60 (37.0%) Blood identified pathogens c Staphylococus spp 7 (43.8%) Streptoccocus spp 1 (6.3%) Gram negative bacteria 7 (43.8%) Other 1 (6.3%) Spinal tap Not performed 121 (74.7%) Positive CSF culture 31 (19.1%) Negative CSF culture 10 (6.2%) CSF identified pathogens Staphylococus spp 13 (41.9%) Streptococcus spp 1 (3.2%) Gram negative bacteria 14 (45.2%) Other bacteria 3 (9.7%) Values are expressed as absolute number (%).; a sum is > 162 because several patients had more than one postoperative neurosurgical infection; b sum is > 132 because several patients had mixed aerobic and anaerobic infections; c sum is > 11 because several patients had > 1 microorganism in blood cultures .One quarter of the patients had an epidural abscess, one fifth a scalp infection, followed by postsurgical meningitis and cranioplasty infections. Staphyloccoccus spp and Gram negative bacteria were the microorganisms most frequently from the drained pus. Same microorganisms were isolated from blood and CSF. Laboratory studies at diagnosis of PINI Laboratory data from blood and CSF are presented in Table 4 . Table 4 Laboratory studies at diagnosis of postoperative intracranial Neurosurgical infections (PINI) Patients (n = 162) Blood determinations Total leukocyte counts cells/µL (n = 162) 9750 (7170.0-13600.0) Absolute neutrophil counts cells/µL (n = 162) 7480.0 (5200.0-11600.0) C-reactive protein mg/L (n = 110) 6.6 (1.9–20.5) Erythrocyte sedimentation rate mm/h (n = 16) 45.0 (31.0-64.8) Creatinine mg/dl (n = 162) 0.7 (0.5–0.8) Glucose mg/dl (n = 162) 108.0 (95.0-136.0) CSF Total leukocyte counts cells/µL (n = 41) 440 (74.0-5000.0) Absolute neutrophil counts cells/µL (n = 41) 711 (41.5–4470.0) Glucose mg/dl (n = 41) 43.0 (33.5–71.5) Proteins mg/dl (n = 41) 31.0 (2.75–113.0) Values are expressed as median (IQ range) Leukocytosis with neutrophilia and increased values of C-reactive protein (C-RP) and erythrocyte sedimentation rate (ESR) were the dominant findings in blood parameters .Similar increase of leukocytes and neutrophils was observed in CSF: Surgical corrective treatment of PINI Most of the patients underwent a surgical corrective procedure detailed in Table 5 . Table 5 Surgical corrective treatment of postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Surgical procedure a Yes 138 (85.2%) No 24 (14.8%) Surgical corrective procedure type a Pus drainage by craniotomy 56 (40.3%) Pus drainage by burr hole and aspiration 5 (3.6%) Cranioplasty change 9 (6.5%) CSF leakage closure 12 (8.6%) Other surgery 57 (41.0%) Number of surgical procedures 0 24 (15.5%) 1 95 (61.3%) 2 20 (12.9%) 3 7(4.5%) 4 9 (5.8%) Values are expressed as absolute number (%). a Sum is > 138 because several patients underwent more than one surgical correction procedure Pus drainage by craniotomy was the most frequent corrective surgery and 8.6% underwent a CSF leakage closure. One fourth needed more than one corrective surgery. Antimicrobial therapy of PINI These results are shown in Table 6 . Table 6 Antimicrobial therapy of postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Antimicrobial therapy before surgery Yes 55 (34.0%) No 107 (66.0)% Pre-operative prophylaxis Cefazolin 104 (64.9%) ∗ Vancomycin 7 (4.2%) Other antimicrobial 13 (8.4%) No 28 (16.8%) Unknown 10 (24.6%) Antimicrobial therapy after infection diagnosis Amoxicillin/clavulanate 12 (7.4%) Cefazolin 2 (1.2%) Carbapenems 3 (1.9%) Piperacillin-tazobactam 1 (0.6%) Other β-lactams 2 (1.2%) Vancomycin 3 (1.9%) Linezolid 2 (1.2%) Quinolones 9 (5.6%) Other single antimicrobial 3 (1.9%) Combined antimicrobial regimen 125 (77.2%) Switch of the initial antimicrobial regimen Yes 138 (85.2%) No 24 (14.8%) n = 138 Reason for antimicrobial regimen switch Culture result 106 (76.8%) Poor evolution 10 (7.2%) Antimicrobial side effects 4 (2.9%) Other reason 18 (13.0%) n = 138 Antimicrobial therapy after the switch Amoxicillin/Clavulanate 6 (4.3%) Cefazolin 4 (2.9%) Carbapenems 10 (7.2%) Piperacillin/tazobactam 1 (0.7%) Other β-lactams 22 (15.9%) Clindamycin 3 (2.2%) Vancomycin 7 (5.1%) Linezolid 10 (7.2%) Aminoglycosides 1 (0.7%) Other single antimicrobial 17 (12.3%) Combined antimicrobial regimen 57 (41.3%) Median duration antimicrobial therapy before the switch days 5.0 (3.0–7.0) Total number of antimicrobials used during hospital stay 3.0 (2.0–4.0) Median duration of antimicrobial used during hospital stay days 21.0 (12.5–31.5) Antimicrobial therapy after hospital discharge Yes 99 (61.1%) No 63 (38.9%) n = 99 Antimicrobials used after hospital discharge Amoxicillin/clavulanate 7 (7.1%) Cefuroxime 1 (1.0%) Clindamycin 2 (2.0%) Quinolones 31 (31.3%) Cotrimoxazole 5 (5.1%) Other antimicrobial 23 (23.2%) Combined antimicrobial regimen 30 (30.3%) Total number of antimicrobials used after hospital discharge 4.0 (3.0.0–4.0) Mean duration of antimicrobial therapy after hospital discharge days 42.0 (25.0–60.0) Values are expressed as median (IQ range) or absolute number (%). Antimicrobial therapy characteristics administered to PINI patients are shown in Table 6 . One third of the cases were on antimicrobials before PINI diagnosis. Over three-quarters had received pre-operative prophylaxis, mostly with cefazolin. Over three-quarters of patients received an initial combined IV antimicrobial regimen that was mostly switched after a median of 5 days to a second IV antimicrobial regimen mainly after culture results. The most frequent initial antimicrobial IV combinations were meropenem + linezolid in 31 (19.1%) cases, meropenem + vancomycin in 24 (14.8%) and vancomycin + other antimicrobial in 10 (6.2%) cases. The second IV antibiotic regimen was a combined one in roughly half of the patients. The most frequently used antimicrobial combination after switch was meropenem + other antimicrobial in 13 (8.0%) cases. The complete IV antimicrobial therapy extended to a median of 21 days using a median of 3.0 antimicrobials of diverse classes. Roughly two-thirds of PINI cases were discharged from the hospital on oral antibiotics. This oral regimen was based on quinolones in 47 (47.5%) cases, in 31 of them (31.3%) as monotherapy Overall the antimicrobial regimen IV plus oral lasted a median of 42. days. Healthcare and outcome characteristics of PINI These results are shown in Table 7 . Table 7 Hospital stay and outcome characteristics of patients with postoperative intracranial neurosurgical infections (PINI) Patients (n = 162) Hospital stay time days 34 (17.5–64.8) Overall follow-up time days 279 (78.0-918.5) Cure Complete cure 132 (81.5%) Relapse 18 (11.1%) No cure 12 (7.4%) Overall death 41 (25.3%) Death related to the infection 11 (6.8%) Values are expressed as median (IQ range,) or absolute number (%). The median length of hospital stay for PINI was slightly more than one month and they were followed at the outpatient’s clinic during a median of 9 months after hospital discharge. Regarding PINI outcome, over four-fifths reached a complete cure, 11.1% relapsed and 7.4% failed to cure. A 6.8% died for reasons related to the neurosurgical infection while 18.5% died for other reasons. Univariate and multivariate analysis of independent factors associated with cure and mortality in PINI Results of the univariate and multivariate analysis are shown in Tables 8 and 9 . Table 8 Univariate analysis of independent factors associated with cure and mortality outcomes in patients with postoperative intracranial neurosurgical infections OR 95% CI P value Cure Other neurosurgery a 1.194 1.127–1.264 < 0.001 Scalp suture infection 1.122 1.015–1.242 0.025 Combined initial IV antimicrobial regimen with vancomycin + other antimicrobial b 1.350 1.190–1.531 < 0.001 Other initial combined antimicrobial regimen b, c 1.197 1.024-1.400 0.024 Switch of the initial IV antimicrobial regimen 0.833 0.802–0.866 < 0.001 Switch of the initial IV antimicrobial regimen to a combined antimicrobial regimen d 1.145 1.071–1.224 < 0.001 Switch to a combined IV antimicrobial regimen with quinolones + cotrimoxazole e 1.188 1.060–1.332 0.003 Switch to a combined IV antimicrobial regimen with amoxicillin/clavulanate + other antimicrobial e 1.188 1.06–1.332 0.003 Oral antimicrobial therapy after hospital discharge 1.168 1.063–1.284 0.001 Mortality HR 95% CI P value Male gender 1.799 1.034–3.128 0.038 Age > 60 years 2.643 1.130–6.182 0.025 Diabetes 2.882 1.819–4.568 < 0.001 Immunodepression 2.608 1.333–5.101 0.005 Scalp suture infection 0.339 0.149–0.773 0.010 Cranioplasty infection 0.468 0.326–0.671 < 0.001 Post-neurosurgical meningitis 2.160 1.095–4.260 0.026 Other post neurosurgical infection f 2.229 1.148–4.328 0.018 Combined antimicrobial regimen 5.684 2.087–15.483 0.001 Other initial combined IV antimicrobial regimen b, c 0.409 0.197–0.846 0.016 Oral antimicrobial therapy after hospital discharge 0.462 0.203–1.053 0.066 a other neurosurgery excluding craniectomy and cranioplasty compared to craniotomy b compared to patients treated with IV carbapenems + aminoglycosides c other initial IV antimicrobial combinations excluding the combinations carbapenem + vancomycin and amoxicillin/clavulanate + vancomycin d compared to patients switched to an antimicrobial IV monotherapy regimen e compared to the patients treated with IV quinolones in monotherapy f other post-neurosurgical infections excluding scalp suture infection, bone flap osteomyelitis, epidural abscess, subdural abscess, brain abscess and meningitis OR = Odds ratio; HR = Hazard ratio; 95% CI = confidence interval Table 9 Multivariate analysis of independent factors associated with cure and mortality outcomes in patients with postoperative intracranial neurosurgical infections OR 95% CI P value Cure Other neurosurgery a 1.240 1.184–1.298 60 years 3.880 1.009–14.917 0.048 Diabetes 2.300 1.202–4.403 0.012 Immunodepression 2.211 1.228–3.980 0.008 Post-neurosurgical meningitis 2.737 1.089–6.878 0.032 Other post neurosurgical infection b 5.533 1.430-21.567 0.013 Combined initial IV antimicrobial regimen 6.279 2.061–19.127 0.001 OR = Odds ratio; HR = Hazard ratio; CI = confidence interval a Other neurosurgery excluding craniectomy and cranioplasty, compared to craniotomy b Other post-neurosurgical infections excluding scalp suture infection, bone flap osteomyelitis, epidural abscess, subdural abscess, brain abscess and meningitis OR = Odds ratio; HR = Hazard ratio; 95%CI = confidence interval Cure Scalp suture and other neurosurgeries (excluding craniectomy and cranioplasty) compared to craniotomy were associated with cure in the univariate analysis (p < 0.03). Also the use of a combined initial IV antimicrobial therapy containing vancomycin + other antimicrobial compared to carbapenems + aminoglycosides and the switch of the initial IV antibiotic treatment to a combined IV regimen made of quinolones + cotrimoxazole, of amoxicillin/clavulanate + other antimicrobial or to other different antimicrobial combination compared to quinolones monotherapy were associated with cure (p < 0.03). Finally, the administration of oral antimicrobials after hospital discharge was also associated with cure in the univariate analysis (p = 0.001). The multivariate analysis showed that undergoing a neurosurgical procedure different from craniectomy and cranioplasty, compared to craniotomy, and receiving oral antimicrobial therapy after hospital discharge were significantly associated with cure (p 60 years, diabetes, immunodepression, undergoing other neurosurgical procedures (different from scalp suture infection, bone flap osteomyelitis, epidural, subdural and brain abscesses) were associated with higher mortality (p < 0.04) in the univariate and multivariate analysis. Individually, cranioplasty infections were associated with higher survival (p < 0.001) while postsurgical meningitis were associated with higher mortality (p = 0.026) An initial combined IV antimicrobial therapy was associated with higher mortality ( p = 0.001) in the univariate and multivariate analysis except for a combined antimicrobial regimen different from carbapenems + vancomycin and amoxicillin/clavulanate + vancomycin, compared to carbapenems + aminoglycosides in the univariate analysis (p = 0.016). Oral antimicrobial therapy after hospital discharge showed a marginal effect on survival on survival (p = 0.066) in the multivariate analysis. Discussion We observed that an extended sequential 6 weeks antimicrobial therapy in addition to neurosurgical correction was significantly associated with PINI cure and might increase patients´ survival in this study. Patients received a median of 3 weeks of IV antimicrobials, mainly as a combined regimen and other 3 weeks of oral antimicrobials after hospital discharge. In the multivariate analysis oral antimicrobial therapy after hospital discharge (p = 0.001) was significantly associated with PINI cure and had a marginal improving effect on survival (p = 0.066). These results were obtained after retrospectively analyze 162 PINI episodes from 8 Spanish third-level academic hospitals in the period 2014-23. The observation of a significantly increased cure and lower mortality rates of PINI after minor neurosurgical procedures different from craniectomy and cranioplasty, compared to craniotomy in the multivariate analysis seems reasonable. Both neurosurgical procedures imply opening of the dura mater membrane or its physical contact with previously stored autologous or synthetic bone to restore the normal shape of the skull. Therefore both surgical procedures might enhance PINI. The overall rate of complications related to cranioplasty after craniectomy is not negligible. Chang et al reported 13% of infection in 212 patients that underwent cranial repair after craniectomy [ 16 ]. In addition neurosurgical procedures different from scalp suture infection, bone flap osteomyelitis, epidural, subdural and brain abscess and meningitis were significantly associated with higher mortality. The surgical correction of infected scalp wounds with simple wound cleaning, of infected cranioplasties with their removal, of intracranial abscesses with pus drainage procedures mainly by a small burr hole and of CSF leakages closure with stitches or graft patches are minor surgical procedures that lead to a shorter hospital stay and a higher survival rate than other more aggressive neurosurgical approaches. We found an association of PINI mortality with age > 60 years, diabetes or immunodepression in the multivariate analysis. These variables are known to be associated with an increased risk of developing a neurosurgical infection after craniotomy [ 9 , 11 ]. However we could not demonstrate an association of PINI cure or mortality with male gender, length of hospital stay before surgery, duration of operation (> 4 hours), number of operations (> 1), or nontraumatic reason of surgery that other authors found [ 1 , 2 , 4 , 6 – 12 ]. Probably the relatively small size of our cohort limited the statistical analysis. In spite of the lack of association of CSF leakage with PINI mortality in our study, previously reported by others, an association of post-neurosurgical meningitis, favored by the CSF-leakage, with mortality was demonstrated in our work [ 1 , 9 ]. Most of the microorganisms isolated from pus drainage, blood or CSF of our patients, mainly Staphyloccosus spp were similar to those identified in previous series [ 1 , 4 , 6 , 8 , 11 ]. Interestingly more than one third of isolates of our PINI cases were Gram negative bacilli in a number much higher than previous works. This fact might suggest that in those cases Gram negative bacilli from the hospital flora colonized the neurosurgical wounds enhancing PINI. Overall 16.8% of our PINI patients did not receive pre-operative antimicrobial prophylaxis. One of the explanations for this fact might be that almost one third of the cases underwent urgent surgery due to vascular or trauma reasons. Buffet-Bataillon et al in a study of 883 patients recruited in the period 2008–2009 in France found that emergence neurosurgical procedures were associated with an increased risk of surgical site infections [ 17 ]. Antibiotic prophylaxis decreased infection rate from 97–5.8% in 4578 patients undergoing craniotomy [ 1 ]. Mollman and Haines performed a case-control analysis on 9,202 patients with neurosurgical wounds and found that antibiotic prophylaxis was associated with a decreased rate of surgical site infection [ 18 ]. However, we could not observe a worse evolution in those PINI patients that did not receive pre-operative antimicrobial prophylaxis. Furthermore an increased PINI cure rate or increased survival in our patients that were receiving antimicrobial therapy previously to neurosurgery was not found, either. There are not standard antimicrobial guidelines for PINI treatment [ 13 – 15 ]. Therefore many antimicrobials in monotherapy and multiples antibiotic combinations were used to treat PINI in our series precluding the statistical analysis of these variables. Although we observed a significant association of some combined initial IV antimicrobial regimens, some of them containing vancomycin (carbapenem + vancomycin, amoxicillin/clavulanate + vancomycin) with PINI cure when compared to the combination of carbapenems + aminoglycoside in the univariate analysis, the instauration of a combined antimicrobial therapy was nor associated with cure in the multivariate analysis (p = 0.202). Surprisingly a combined initial IV antimicrobial regimen was significantly associated with higher mortality (p = 0.001). This unexpected finding could be explained by the fact that patients with more severe PINI were started on empiric combined IV antimicrobial regimens due to their serious clinical situation more frequently than those with minor PINI that were put initially on IV antimicrobial monotherapies. Our results of a median of 3 weeks of IV antimicrobial therapy for PINI shorten to a half the guidelines made by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) that recommend 6–8 weeks of IV antimicrobials for aspirated or conservatively treated brain abscesses. However only 62 patients of our study (38.3%) had a CNS abscess and 19.8% had other had other infections such as scalp´s (19.8% ) that did not require long IV antimicrobial therapy. The same ESCMID guidelines do not recommend neither early transition to oral antimicrobials nor oral consolidation treatment after > 6 weeks of IV antimicrobials for brain abscess. Extended oral antimicrobial therapy after hospital discharge was significantly associated with cure in our PINI cases .This oral therapy was combined in one third of cases and was based on single or combined quinolones regimens. Quinolones cross easily the blood-brain barrier and through the bacterial-generated biofilm and are ideal antimicrobials to treat PINI especially with foreign body devices such as cranioplasty grafts. [ 13 – 15 ]. Regarding PINI outcome four fifths of our PINI patients cured, 11.8% relapsed and one fourth died but only 6.8% due to PINI. Bodilsen et al in a recent meta-analysis found a relapse or recurrence rate of 3.4% in children and adults with brain abscesses treated with IV antimicrobials for > 6 weeks and surgical pus drainage [ 16 ]. However 26% of our PINI patients had cranioplasty infections or skull osteomyelitis with a very high relapse rate, higher than CNS abscess The mortality rate due to PINI in our cases, in whom one fifth was immunodepressed and one fourth had comorbiditites was slightly higher than the 4.7% reported by Korinek et al in France in a large prospective cohort of 383 PINI patients after 6243 consecutive craniotomies. However when these authors considered only those patients with postsurgical meningitis the mortality raised to 13.7% [ 3 ]. A fatality rate of 4.4% was observed in 45 Indian patients with subdural empyema treated with pus drainage and broad-spectrum antibiotics [20]. Bodilsen et al in a recent meta-analysis found a fatality rate of 9% in children and adults with brain abscess treated with aspiration or excision [ 19 ]. The main strength of this work relies on its focus on PINI antimicrobial therapy, a point neglected by most of the previous studies on this topic, the relatively large sample size and the elevated number of parameters assessed, which allowed to adjust for and minimize the effect of confounders in the uni and multivariate analysis. Limitations include those common to retrospective studies, the long time needed, 9 years, for closing the study due to the interfering COVID-19 pandemia, the absence of a unified antimicrobial treatment protocol for PINI, which would allow the evaluation of the responses to the same treatment, and the variability characteristic of multicenter studies, particularly regarding procedural and management aspects. However, as we have mentioned before, currently no single or widely accepted treatment protocol exists considering the great diversity of clinical and microbiological issues related to PINI, and the multicenter character of the study allows the evaluation of the real clinical practice across our country, minimizing potential biases from a single institution. Conclusions We conclude that an extended 6 weeks sequential IV for 3 weeks and oral antimicrobial therapy for other 3 weeks in addition to neurosurgical correction increases PINI cure rate and might improve patients´ survival . Abbreviations CI :confidence interval; CNS: Central Nervous System; C-RP: C-reactive protein; CSF: Cerebrospinal fluid; CT:computerized tomography; ESR: erythrocyte sedimentation rate; GCS: Glasgow Coma Scale; HR: hazard rate; ICU: Intensive Care Unit; IV: intravenous; ID: Infectious Diseases; MRI: magnetic resonance imaging; OR :Odds ratio; PINI : Postoperative intracranial neurosurgical infections Declarations Acknowledgements The authors thank the Infectious Diseases Working Group of the Spanish Society of Internal Medicine (SEMI) for help promoting and funding this study. This organization had no role in the study design, collection, Ethics approval and consent to participate :This was an observational study, using anonymized data, in which the patients underwent routine clinical care for PINI, without any change in its management or specific determinations or procedures. Therefore, no formal written informed consent was obtained from the patients. The Research Ethics Committee of the Principality of Asturias granted a formal waiver of ethical approval for this study. Consent for publication Not applicable Availability of data and materials Not applicable Competing interest The authors declare that they have no competing interest . Funding The Infectious Diseases Working Group of the Spanish Society of Internal Medicine (SEMI) supported and funded this study Authors’ contributions C.V., H.G., S.S.-D., E.A.-D.;N.C.-A., A.G.-R.,M.V.M., J.M.G., J.A., M.A.S., X.G.-C., C.D., and M.B. recruited patients and collected the data, JC designed the study data file, VC did the statistical analysis of the data and VA designed the study, recruited patients, collected data and wrote the manuscript. All authors have read and approved the final version manuscript. References Korinek AM, Golmard JL, Elcheick A, Bismuth R, van Effenterre R, Coriat P, et al. Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg. 2005;19:155–62. 10.1080/02688690500145639 . Erman T, Demirhindi H, Göçer AI, Tuna M, Ildan F, Boyar B. Risk factors for surgical site infections in neurosurgery patients with antibiotic prophylaxis Surg Neurol. 2005; 63:107 – 12; discussion 112-3. 10.1016/j.surneu.2004.04.024 Korinek AM, Baugnon T, Golmard JL, van Effenterre R, Coriat P, Puybasset L. Risk Factors for Adult Nosocomial Meningitis after Craniotomy Role of Antibiotic Prophylaxis. Neurosurgery. 2006;59:126–33. 10.1227/. 01.neu. 0000243291. 61566.21. McClelland S 3rd, Hall WA. Postoperative central nervous system infection: incidence and associated factors in 2111 neurosurgical procedures. Clin Infect Dis. 2007;45:55–9. 10.1086/518580 . McClelland S 3. Postoperative intracranial neurosurgery infection rates in North America versus Europe: a systematic analysis. Am J Infect Control. 2008;36:570–3. 10.1016/j.ajic.2007.07.015 . Zhan R, Zhu Y, Shen Y, Shen J, Tong Y, Yu H, et al. Post-operative central nervous system infections after cranial surgery in China: incidence, causative agents, and risk factors in 1,470 patients. Eur J Clin Microbiol Infect Dis. 2014;33:861–6. 10.1007/s10096-013-2026-2 . Golebiowski A, Drewes C, Gulati S, Jakola AS, Solheim O. Is duration of surgery a risk factor for extracranial complications and surgical site infections after intracranial tumor operations? Acta Neurochir (Wien). 2015;157: 235 – 40;. 10.1007/s00701-014-2286-3 Hamdeh SA. E Surgical site infections in standard neurosurgery procedures- a study of incidence, impact and potential risk factors. Br J Neurosurg. 2014;28:270–5. 10.3109/02688697.2013.835376 . , Lytsy B, Ronne-Engström. Fang C, Zhu T, Zhang P, Xia L, Sun C. Risk factors of neurosurgical site infection after craniotomy: A systematic review and meta-analysis. Am J Infect Control. 2017;45:e123–34. 10.1016/j.ajic.2017.06.009 . Torres S, Baria Perdiz L, Medeiros EA. Incidence of surgical site infection after craniotomy: comparison between three months and twelve months of epidemiological surveillance. Braz J Infect Dis. 2018;22:433–7. 10.1016/j.bjid.2018.08.001 . Wang LY, Cao XH, Shi LK, Ma ZZ, Wang Y, Liu Y. Risk factors for intracranial infection after craniotomy: A case-control study. Brain Behav. 2020;10:e01658. 10.1002/brb3.1658 . Adapa AR, Linzey JR, Moriguchi F, Daou BJ, Khalsa SSS, Ponnaluri-Wears S, et al. Risk factors and morbidity associated with surgical site infection subtypes following adult neurosurgical procedures. Br J Neurosurg. 2024;38:503–9. 10.1080/02688697.2021.1905773 . Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan SL, Scheld WM, et al. 2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clin Infect Dis. 2017;64:e34–65. 10.1093/cid/ciw861 . Conen A, Raabe A, Schaller K, Fux CA, Vajkoczy P, Trampuz A. Management of neurosurgical implant-associated infections. Swiss Med Wkly. 2020;150:w20208. 10.4414/smw.2020.20208 . Bodilsen J, D'Alessandris QG, Humphreys H, Iro MA, Klein M, Last K, et al. European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults. Clin Microbiol Infect. 2024;30:66–89. 10.1016/j.cmi.2023.08.016 . Chang V, Hartzfeld P, Marianne Langlois M, Mahmood A, Seyfried D. Outcomes of cranial repair after craniectomy. J Neurosurg. 2010;112:1120-4. 10.3171/ 2009.6. JNS09133. Mollman HD, Haines SJ. Risk factors for postoperative neurosurgical wound infection. A case-control study. J Neurosurg. 1986;64:902–6. 10.3171/jns.1986.64.6.0902 . Buffet-Bataillon S, Saunders L, Campillo-Gimenez B, Haegelen C. Risk factors for neurosurgical site infection after neurosurgery in Rennes, France: comparison of logistic and Cox models. Am J Infect Control. 2013;41:1290–2. 10.1016/j.ajic.2013.02.006 . Tewari MK, Sharma RS, Shiv VK, Lad SD. Spectrum of intracranial subdural empyemas in a series of 45 patients: current surgical options and outcome. Neurol India. 2004;52:346–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 22 Aug, 2024 Editor assigned by journal 22 Aug, 2024 Submission checks completed at journal 22 Aug, 2024 First submitted to journal 20 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4946614","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":343693376,"identity":"9947ea42-c20a-4a4b-a4bd-784234ac355d","order_by":0,"name":"Víctor Asensi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYPACCQZ+EJVQQIoWyQaQFgNS7DE4ACaJUXn8+MPHBX8s5I3Pr0788MCAQZ5f7AABLWdyjI1ntkkYbrvxdrME0GGGM2cn4Nci2ZDDJs3bIMG47cbZDSAtCQa3CWnpf/78N88fCfvNM85u/kGUFn6JBDNmHjaJxA38vduIs4Vf4o2xNG+bRPKMG7zbLBIMJAj7hY0//eFnnj91tv39Zzff/FFhI88vTUALAkiAVUoQqxzsxAOkqB4Fo2AUjIKRBACqQED+cT3/AAAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital Universitario Central de Asturias","correspondingAuthor":true,"prefix":"","firstName":"Víctor","middleName":"","lastName":"Asensi","suffix":""},{"id":343693377,"identity":"239cd0c6-0aeb-46c2-ae8d-dcb531a67490","order_by":1,"name":"C. Vázquez","email":"","orcid":"","institution":"Hospital Universitario Central de Asturias","correspondingAuthor":false,"prefix":"","firstName":"C.","middleName":"","lastName":"Vázquez","suffix":""},{"id":343693378,"identity":"f0f2718d-e805-44c8-95e9-105f4552dd86","order_by":2,"name":"S. Suárez-Díaz","email":"","orcid":"","institution":"Hospital Universitario Central de Asturias","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"","lastName":"Suárez-Díaz","suffix":""},{"id":343693379,"identity":"a5ff257a-f027-4059-9293-b1d6c0be1cd0","order_by":3,"name":"E. Asensi-Díaz","email":"","orcid":"","institution":"Hospital Universitario Fundación Jiménez Díaz","correspondingAuthor":false,"prefix":"","firstName":"E.","middleName":"","lastName":"Asensi-Díaz","suffix":""},{"id":343693380,"identity":"c5168cf3-aac9-4ab9-9ed1-ce2defe31c07","order_by":4,"name":"N. Carrasco-Antón","email":"","orcid":"","institution":"Hospital Universitario Fundación Jiménez Díaz","correspondingAuthor":false,"prefix":"","firstName":"N.","middleName":"","lastName":"Carrasco-Antón","suffix":""},{"id":343693381,"identity":"7bbf0d9f-5b08-4a6c-ae99-97222a5a92e9","order_by":5,"name":"A. García-Reyne","email":"","orcid":"","institution":"Hospital 12 Octubre","correspondingAuthor":false,"prefix":"","firstName":"A.","middleName":"","lastName":"García-Reyne","suffix":""},{"id":343693382,"identity":"c7e4d4ec-9d0a-432e-af5e-221962e803f9","order_by":6,"name":"Irene Panero","email":"","orcid":"","institution":"Hospital 12 Octubre","correspondingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Panero","suffix":""},{"id":343693383,"identity":"d0606105-c505-49d8-9489-81e3e3f08dbe","order_by":7,"name":"María Victoria Muñoz","email":"","orcid":"","institution":"Complejo Hospitalario de León","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Victoria","lastName":"Muñoz","suffix":""},{"id":343693384,"identity":"3c792de2-7d11-4af7-bbd3-f54d4247590c","order_by":8,"name":"José Manuel Guerra","email":"","orcid":"","institution":"Complejo Hospitalario de León","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Manuel","lastName":"Guerra","suffix":""},{"id":343693386,"identity":"a8ac8644-667b-4f0a-92f0-ae14ece8c376","order_by":9,"name":"Javier Arístegui","email":"","orcid":"","institution":"Hospital Universitario de Toledo","correspondingAuthor":false,"prefix":"","firstName":"Javier","middleName":"","lastName":"Arístegui","suffix":""},{"id":343693387,"identity":"e5f786c0-54fa-43d6-abdb-336e22c9da87","order_by":10,"name":"María Antonia Sepúlveda","email":"","orcid":"","institution":"Hospital Universitario de Toledo","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Antonia","lastName":"Sepúlveda","suffix":""},{"id":343693388,"identity":"a6406035-15e2-4570-80ca-fd608285b6c8","order_by":11,"name":"Xavier García-Calvo","email":"","orcid":"","institution":"Hospital Universitario Germans Trias i Pujol","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"García-Calvo","suffix":""},{"id":343693390,"identity":"6a879db6-caed-4745-8a91-790a11e0823d","order_by":12,"name":"Carlos Dueñas","email":"","orcid":"","institution":"Hospital Clínico Universitario de Valladolid","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"","lastName":"Dueñas","suffix":""},{"id":343693392,"identity":"42e7af5f-51d2-4daa-a19e-b7f2047f293a","order_by":13,"name":"Mercé Biosca","email":"","orcid":"","institution":"Hospital Vall d´Hebrón","correspondingAuthor":false,"prefix":"","firstName":"Mercé","middleName":"","lastName":"Biosca","suffix":""},{"id":343693395,"identity":"3a81b918-b75e-475f-ba84-e8e4a5df1d59","order_by":14,"name":"Valentina Chiminazzo","email":"","orcid":"","institution":"FINBA-ISPA","correspondingAuthor":false,"prefix":"","firstName":"Valentina","middleName":"","lastName":"Chiminazzo","suffix":""},{"id":343693397,"identity":"bfa84b09-95c1-42d7-9337-9ca6c5edd4de","order_by":15,"name":"Julio Collazos","email":"","orcid":"","institution":"Hospital de Galdakao-Usánsolo","correspondingAuthor":false,"prefix":"","firstName":"Julio","middleName":"","lastName":"Collazos","suffix":""}],"badges":[],"createdAt":"2024-08-20 16:51:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4946614/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4946614/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-024-10204-7","type":"published","date":"2024-11-26T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70382588,"identity":"10c03717-96f9-4e0a-a4af-48a51a10a3c4","added_by":"auto","created_at":"2024-12-02 16:28:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1055554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4946614/v1/fe4f013c-7bde-47ba-b4b3-ad1819b1b227.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Extended sequential intravenous and oral antimicrobial therapy improves cure rate in postoperative intracranial neurosurgical infections. A Spanish multicenter retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003ePostoperative intracranial neurosurgical infections (PINI) complicate\u0026thinsp;\u0026lt;\u0026thinsp;5% of all neurosurgeries [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]., with lower infection rates reported in American series [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Extensive consideration has been paid so far to infections of other neurosurgical procedures such as external and internal cerebrospinal fluid (CSF) shunts and other implantable neural devices, mostly to CSF shunts ventriculitis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However scarce attention has been dedicated to PINI, with efforts mainly focused on PINI risk factors but not on their treatment. This is especially surprising considering that PINI have a high morbidity, not negligible mortality, generate delayed hospital stays and increase greatly healthcare costs. PINI treatment necessitates in most of the cases a second neurosurgical intervention or even more to achieve cure. In addition, PINI therapy requires specific antimicrobials, used in high doses, able to cross the blood-brain barrier, with activity again methicillin-resistant staphylococci in many cases, and not exempt of side effects. Furthermore, PINI antimicrobials need to be administer intravenously (IV) several times a day for several weeks through a central catheter complicating nursing work. Frequently used antimicrobial guidelines are not explicit for PINI regarding the type of antibiotic to be used, alone or in combination, its administration route, switching time from IV to oral, and total duration of therapy [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For all these reasons we underwent this retrospective study on PINI focusing especially on the characteristics and duration of their antimicrobial management and their influence on cure and mortality outcomes.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003ePatients with 18 years or older diagnosed with PINI admitted to the Neurosurgery wards of Hospital Universitario Central de Asturias (HUCA), Oviedo, Hospital Universitario Fundaci\u0026oacute;n Jim\u0026eacute;nez Diaz, Madrid, Hospital 12 de Octubre, Madrid, Complejo Universitario de Le\u0026oacute;n, Hospital Universitario de Toledo, Hospital Universitario Germans Trias i Pujol, Badalona, Hospital Cl\u0026iacute;nico Universitario de Valladolid and Hospital Vall d\u0026acute;Hebron; Barcelona, all in Spain, between May 1st 2014 and May 15th 2023 were included in the study. The diagnosis of PINI was primarily based on history, physical examination, microbiological, neuroimaging diagnostic procedures (head CT and/or MRI), and surgical findings at the operation room. The patients were followed a median of 9 months after hospital discharge by both a neurosurgeon and an Infectious Diseases (ID) consultant at each of the participant hospitals. The response to treatment was evaluated by the neurosurgeon in charge of the patient, based on clinical and neuroimaging findings and confirmed by the ID consultant PINI. cure implied absence of physical and neuroimaging signs of infection and lack of relapses or hospital re-admissions for neurosurgical infectious reasons during the follow-up. PINI relapse implied failure to cure, or initial response but relapse within 9 months of hospital discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria\u003c/h2\u003e \u003cp\u003ePatients younger than 18 years, those with CNS infections due to external and internal (ventriculoperitoneal and ventroculoatrial) CSF shunts and to neurostimulators and those with spinal infections were excluded .\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collecting\u003c/h2\u003e \u003cp\u003eMany demographic, epidemiological, topographic, microbiological, clinical, laboratory, imaging, prognostic, hospitalization, and therapeutic (both surgical and antibiotic) data were collected and analyzed according to the PINI response to surgical and antimicrobial therapy. Regarding the diverse PINI, positive cultures obtained from blood, CSF, operation room drained pus collections and infected neurosurgical wounds exudates were considered.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics was reported as median with interquartile range (IQR) for continuous variables and absolute numbers with percentages for categorical variables. Univariable and multivariable logistic regression and Cox proportional hazard models were employed to assess the effect of the variables of interest on PINI cure and mortality, respectively. The referring hospital was included in each model as a cluster to take into account that patients coming from the same hospital are more similar to each other. To avoid overfitting, variables included in the multivariable models were identified by performing a backward selection based on the Akaike Information Criterion (BIC). Results of logistic regression models were reported as Odds Ratio (OR) with its 95% confidence interval (95%CI) and p-value, while results of Cox regression models were reported as Hazard Ratio (HR) with its 95% confidence interval (CI) and p-value.\u003c/p\u003e \u003cp\u003eThe analyses were performed using R software (version 4.3.2). R Core Team (2023). R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics of patients with PINI and predisposing factors leading to these infections\u003c/h2\u003e \u003cp\u003eThe characteristics of the patients regarding gender, age and predisposing factors for PINI are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemography, and predisposing factors to postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (46.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eyears\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.4 (47.2\u0026ndash;69.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredisposing factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (85.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Past or present smoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42 (25,9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120 (74.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Alcohol abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e147 (90.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-Previous extracranial infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (19.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (80.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Immunodepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e- Cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(13.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (86.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026hellip;\u0026hellip;.Steroids therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (96.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther immunosuppressive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (93.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther immunosuppression causes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (76.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (24.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e122 (75.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eICU stay before neurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e123 (75.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay before neurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0-0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as median (IQ range) or absolute number (%).\u003c/p\u003e \u003cp\u003e. Interestingly, one fifth had a previous extracranial infection when the PINI was diagnosed. Overall 18.5% had an immunodepression and one quarter carried other comorbidities that could facilitate PINI. Although one quarter of the patients were admitted to the ICU before neurosurgery their ICU stay was so short that did not contribute to PINI.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNeurosurgery-related parameters of PINI\u003c/h2\u003e \u003cp\u003eThe characteristics of neurosurgical procedures leading to PINI are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeurosurgery-related parameters of postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery timing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrgent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (30.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (69.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124 (76.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClean-contaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDirty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCraniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e114 (70.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCraniectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCranioplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (17.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery cause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVascular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74 (45.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0 (2.0\u0026ndash;5.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS at surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.0 (15.0\u0026ndash;15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePostsurgical CSF leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129 (79.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as median (IQ range) or absolute number (%).\u003c/p\u003e \u003cp\u003eGCS\u0026thinsp;=\u0026thinsp;Glasgow Coma Scale ; CSF\u0026thinsp;=\u0026thinsp;cerebrospinal fluid\u003c/p\u003e \u003cp\u003eTwo-thirds of the patients underwent elective, mostly clean, neurosurgery. Craniotomy was the predominant surgical procedure. The cause of neurosurgery was tumor in almost half of the patients followed by a vascular reason. Patients had a full Glasgow Coma Scale (GCS) score when entering the operating room. Surgery lasted a median of 3 hours .The main post-surgical complication was a cerebrospinal fluid (CSF) leakage in one fifth of the cases, enhancing post-surgical meningitis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePINI type, location and microbiology\u003c/h2\u003e \u003cp\u003ePINI type, location and microbiology of the drained pus, blood and CSF samples are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eType, location and microbiology of postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection type \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScalp Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCranioplasty infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkull osteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpidural abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (24.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubdural abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntraparenchymal brain abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection location \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight parieto-temporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (27.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeft parieto-temporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOccipital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot focalized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultured pus samples\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e159 (98.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCulture positive pus samples\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e132 (83.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePus identified pathogens\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle pathogens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58 (43.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStreptococcus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram negative bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (38.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther aerobic bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolimicrobial aerobes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (14.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnaerobes\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (15.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood cultures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot drawn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (56.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (37.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood identified pathogens\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (43.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStreptoccocus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram negative bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (43.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal tap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot performed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (74.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive CSF culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (19.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative CSF culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (6.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSF identified pathogens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (41.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStreptococcus spp\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram negative bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (45.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as absolute number (%).; \u003csup\u003ea\u003c/sup\u003e sum is \u0026gt;\u0026thinsp;162 because several patients had more than one postoperative neurosurgical infection; \u003csup\u003eb\u003c/sup\u003e sum is \u0026gt;\u0026thinsp;132 because several patients had mixed aerobic and anaerobic infections; \u003csup\u003ec\u003c/sup\u003e sum is \u0026gt;\u0026thinsp;11 because several patients had\u0026thinsp;\u0026gt;\u0026thinsp;1 microorganism in blood cultures\u003c/p\u003e \u003cp\u003e.One quarter of the patients had an epidural abscess, one fifth a scalp infection, followed by postsurgical meningitis and cranioplasty infections. \u003cem\u003eStaphyloccoccus spp\u003c/em\u003e and Gram negative bacteria were the microorganisms most frequently from the drained pus. Same microorganisms were isolated from blood and CSF.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory studies at diagnosis of PINI\u003c/h2\u003e \u003cp\u003eLaboratory data from blood and CSF are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory studies at diagnosis of postoperative intracranial Neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eBlood determinations\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal leukocyte counts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecells/\u0026micro;L (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9750 (7170.0-13600.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsolute neutrophil counts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecells/\u0026micro;L (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7480.0 (5200.0-11600.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/L (n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.6 (1.9\u0026ndash;20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythrocyte sedimentation rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emm/h (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0 (31.0-64.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7 (0.5\u0026ndash;0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl (n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108.0 (95.0-136.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCSF\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal leukocyte counts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecells/\u0026micro;L (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e440 (74.0-5000.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsolute neutrophil counts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecells/\u0026micro;L (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e711 (41.5\u0026ndash;4470.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.0 (33.5\u0026ndash;71.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProteins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emg/dl (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.0 (2.75\u0026ndash;113.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as median (IQ range)\u003c/p\u003e \u003cp\u003eLeukocytosis with neutrophilia and increased values of C-reactive protein (C-RP) and erythrocyte sedimentation rate (ESR) were the dominant findings in blood parameters .Similar increase of leukocytes and neutrophils was observed in CSF:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eSurgical corrective treatment of PINI\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eMost of the patients underwent a surgical corrective procedure detailed in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical corrective treatment of postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical procedure\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical corrective procedure type \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePus drainage by craniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (40.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePus drainage by burr hole and aspiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCranioplasty change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCSF leakage closure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (8.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (41.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgical procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (15.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95 (61.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7(4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as absolute number (%).\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Sum is \u0026gt;\u0026thinsp;138 because several patients underwent more than one surgical correction procedure\u003c/p\u003e \u003cp\u003ePus drainage by craniotomy was the most frequent corrective surgery and 8.6% underwent a CSF leakage closure. One fourth needed more than one corrective surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eAntimicrobial therapy of PINI\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThese results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAntimicrobial therapy of postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial therapy before surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (34.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (66.0)%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-operative prophylaxis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCefazolin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (64.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lowast;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther antimicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (16.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (24.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial therapy after infection diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmoxicillin/clavulanate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCefazolin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarbapenems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePiperacillin-tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther β-lactams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLinezolid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuinolones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther single antimicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (77.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwitch of the initial antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e138 (85.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (14.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason for antimicrobial regimen switch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCulture result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106 (76.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor evolution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntimicrobial side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial therapy after the switch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmoxicillin/Clavulanate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCefazolin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarbapenems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePiperacillin/tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther β-lactams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLinezolid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAminoglycosides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther single antimicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (41.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian duration antimicrobial therapy before the switch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 (3.0\u0026ndash;7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of antimicrobials used\u003c/p\u003e \u003cp\u003eduring hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 (2.0\u0026ndash;4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian duration of antimicrobial used during hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.0 (12.5\u0026ndash;31.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobial therapy after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (61.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntimicrobials used after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmoxicillin/clavulanate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCefuroxime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuinolones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (31.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther antimicrobial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (23.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of antimicrobials used after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 (3.0.0\u0026ndash;4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean duration of antimicrobial therapy after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.0 (25.0\u0026ndash;60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as median (IQ range) or absolute number (%).\u003c/p\u003e \u003cp\u003eAntimicrobial therapy characteristics administered to PINI patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. One third of the cases were on antimicrobials before PINI diagnosis. Over three-quarters had received pre-operative prophylaxis, mostly with cefazolin.\u003c/p\u003e \u003cp\u003eOver three-quarters of patients received an initial combined IV antimicrobial regimen that was mostly switched after a median of 5 days to a second IV antimicrobial regimen mainly after culture results. The most frequent initial antimicrobial IV combinations were meropenem\u0026thinsp;+\u0026thinsp;linezolid in 31 (19.1%) cases, meropenem\u0026thinsp;+\u0026thinsp;vancomycin in 24 (14.8%) and vancomycin\u0026thinsp;+\u0026thinsp;other antimicrobial in 10 (6.2%) cases. The second IV antibiotic regimen was a combined one in roughly half of the patients. The most frequently used antimicrobial combination after switch was meropenem\u0026thinsp;+\u0026thinsp;other antimicrobial in 13 (8.0%) cases. The complete IV antimicrobial therapy extended to a median of 21 days using a median of 3.0 antimicrobials of diverse classes.\u003c/p\u003e \u003cp\u003eRoughly two-thirds of PINI cases were discharged from the hospital on oral antibiotics. This oral regimen was based on quinolones in 47 (47.5%) cases, in 31 of them (31.3%) as monotherapy Overall the antimicrobial regimen IV plus oral lasted a median of 42. days.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eHealthcare and outcome characteristics\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eof\u003c/span\u003e \u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ePINI\u003c/span\u003e\u003c/p\u003e \u003cp\u003eThese results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital stay and outcome characteristics of patients with postoperative intracranial neurosurgical infections (PINI)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePatients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (17.5\u0026ndash;64.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall follow-up time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e279 (78.0-918.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplete cure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e132 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo cure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath related to the infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (6.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eValues are expressed as median (IQ range,) or absolute number (%).\u003c/p\u003e \u003cp\u003eThe median length of hospital stay for PINI was slightly more than one month and they were followed at the outpatient\u0026rsquo;s clinic during a median of 9 months after hospital discharge. Regarding PINI outcome, over four-fifths reached a complete cure, 11.1% relapsed and 7.4% failed to cure. A 6.8% died for reasons related to the neurosurgical infection while 18.5% died for other reasons.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eUnivariate and multivariate analysis of independent factors associated with cure and mortality in PINI\u003c/h2\u003e \u003cp\u003eResults of the univariate and multivariate analysis are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e and \u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate analysis of independent factors associated with cure and mortality outcomes in patients with postoperative intracranial neurosurgical infections\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther neurosurgery \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.127\u0026ndash;1.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalp suture infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.015\u0026ndash;1.242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined initial IV antimicrobial regimen with vancomycin\u0026thinsp;+\u0026thinsp;other antimicrobial \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.190\u0026ndash;1.531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther initial combined antimicrobial regimen \u003csup\u003eb, c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.024-1.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwitch of the initial IV antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.802\u0026ndash;0.866\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwitch of the initial IV antimicrobial regimen to a combined antimicrobial regimen \u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.071\u0026ndash;1.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwitch to a combined IV antimicrobial regimen with quinolones\u0026thinsp;+\u0026thinsp;cotrimoxazole \u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.060\u0026ndash;1.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwitch to a combined IV antimicrobial regimen with amoxicillin/clavulanate\u0026thinsp;+\u0026thinsp;other antimicrobial \u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06\u0026ndash;1.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral antimicrobial therapy after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.063\u0026ndash;1.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.799\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.034\u0026ndash;3.128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;60 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.130\u0026ndash;6.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.819\u0026ndash;4.568\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmunodepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.333\u0026ndash;5.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalp suture infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.149\u0026ndash;0.773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCranioplasty infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.326\u0026ndash;0.671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-neurosurgical meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.095\u0026ndash;4.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther post neurosurgical infection \u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.148\u0026ndash;4.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.087\u0026ndash;15.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther initial combined IV antimicrobial regimen \u003csup\u003eb, c\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.197\u0026ndash;0.846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral antimicrobial therapy after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.203\u0026ndash;1.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e other neurosurgery excluding craniectomy and cranioplasty compared to craniotomy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003ecompared to patients treated with IV carbapenems\u0026thinsp;+\u0026thinsp;aminoglycosides\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ec\u003c/sup\u003e other initial IV antimicrobial combinations excluding the combinations carbapenem\u0026thinsp;+\u0026thinsp;vancomycin and amoxicillin/clavulanate\u0026thinsp;+\u0026thinsp;vancomycin\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ed\u003c/sup\u003e compared to patients switched to an antimicrobial IV monotherapy regimen\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ee\u003c/sup\u003e compared to the patients treated with IV quinolones in monotherapy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ef\u003c/sup\u003e other post-neurosurgical infections excluding scalp suture infection, bone flap osteomyelitis, epidural abscess, subdural abscess, brain abscess and meningitis\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOR\u0026thinsp;=\u0026thinsp;Odds ratio; HR\u0026thinsp;=\u0026thinsp;Hazard ratio; 95% CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of independent factors associated with cure and mortality outcomes in patients with postoperative intracranial neurosurgical infections\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther neurosurgery\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.184\u0026ndash;1.298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined antimicrobial therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.838\u0026ndash;1.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral antimicrobial therapy after hospital discharge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.071\u0026ndash;1.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMortality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;60 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.009\u0026ndash;14.917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.202\u0026ndash;4.403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmunodepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.228\u0026ndash;3.980\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-neurosurgical meningitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.737\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.089\u0026ndash;6.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther post neurosurgical infection\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.430-21.567\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined initial IV antimicrobial regimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.061\u0026ndash;19.127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOR\u0026thinsp;=\u0026thinsp;Odds ratio; HR\u0026thinsp;=\u0026thinsp;Hazard ratio; CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eOther neurosurgery excluding craniectomy and cranioplasty, compared to craniotomy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e Other post-neurosurgical infections excluding scalp suture infection, bone flap osteomyelitis, epidural abscess, subdural abscess, brain abscess and meningitis\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOR\u0026thinsp;=\u0026thinsp;Odds ratio; HR\u0026thinsp;=\u0026thinsp;Hazard ratio; 95%CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCure\u003c/h2\u003e \u003cp\u003eScalp suture and other neurosurgeries (excluding craniectomy and cranioplasty) compared to craniotomy were associated with cure in the univariate analysis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.03). Also the use of a combined initial IV antimicrobial therapy containing vancomycin\u0026thinsp;+\u0026thinsp;other antimicrobial compared to carbapenems\u0026thinsp;+\u0026thinsp;aminoglycosides and the switch of the initial IV antibiotic treatment to a combined IV regimen made of quinolones\u0026thinsp;+\u0026thinsp;cotrimoxazole, of amoxicillin/clavulanate\u0026thinsp;+\u0026thinsp;other antimicrobial or to other different antimicrobial combination compared to quinolones monotherapy were associated with cure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.03). Finally, the administration of oral antimicrobials after hospital discharge was also associated with cure in the univariate analysis (p\u0026thinsp;=\u0026thinsp;0.001). The multivariate analysis showed that undergoing a neurosurgical procedure different from craniectomy and cranioplasty, compared to craniotomy, and receiving oral antimicrobial therapy after hospital discharge were significantly associated with cure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.001, respectively).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMortality\u003c/h2\u003e \u003cp\u003eMale gender, age\u0026thinsp;\u0026gt;\u0026thinsp;60 years, diabetes, immunodepression, undergoing other neurosurgical procedures (different from scalp suture infection, bone flap osteomyelitis, epidural, subdural and brain abscesses) were associated with higher mortality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.04) in the univariate and multivariate analysis. Individually, cranioplasty infections were associated with higher survival (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) while postsurgical meningitis were associated with higher mortality (p\u0026thinsp;=\u0026thinsp;0.026) An initial combined IV antimicrobial therapy was associated with higher mortality ( p\u0026thinsp;=\u0026thinsp;0.001) in the univariate and multivariate analysis except for a combined antimicrobial regimen different from carbapenems\u0026thinsp;+\u0026thinsp;vancomycin and amoxicillin/clavulanate\u0026thinsp;+\u0026thinsp;vancomycin, compared to carbapenems\u0026thinsp;+\u0026thinsp;aminoglycosides in the univariate analysis (p\u0026thinsp;=\u0026thinsp;0.016). Oral antimicrobial therapy after hospital discharge showed a marginal effect on survival on survival (p\u0026thinsp;=\u0026thinsp;0.066) in the multivariate analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe observed that an extended sequential 6 weeks antimicrobial therapy in addition to neurosurgical correction was significantly associated with PINI cure and might increase patients\u0026acute; survival in this study. Patients received a median of 3 weeks of IV antimicrobials, mainly as a combined regimen and other 3 weeks of oral antimicrobials after hospital discharge. In the multivariate analysis oral antimicrobial therapy after hospital discharge (p\u0026thinsp;=\u0026thinsp;0.001) was significantly associated with PINI cure and had a marginal improving effect on survival (p\u0026thinsp;=\u0026thinsp;0.066). These results were obtained after retrospectively analyze 162 PINI episodes from 8 Spanish third-level academic hospitals in the period 2014-23.\u003c/p\u003e \u003cp\u003eThe observation of a significantly increased cure and lower mortality rates of PINI after minor neurosurgical procedures different from craniectomy and cranioplasty, compared to craniotomy in the multivariate analysis seems reasonable. Both neurosurgical procedures imply opening of the dura mater membrane or its physical contact with previously stored autologous or synthetic bone to restore the normal shape of the skull. Therefore both surgical procedures might enhance PINI. The overall rate of complications related to cranioplasty after craniectomy is not negligible. Chang et al reported 13% of infection in 212 patients that underwent cranial repair after craniectomy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition neurosurgical procedures different from scalp suture infection, bone flap osteomyelitis, epidural, subdural and brain abscess and meningitis were significantly associated with higher mortality. The surgical correction of infected scalp wounds with simple wound cleaning, of infected cranioplasties with their removal, of intracranial abscesses with pus drainage procedures mainly by a small burr hole and of CSF leakages closure with stitches or graft patches are minor surgical procedures that lead to a shorter hospital stay and a higher survival rate than other more aggressive neurosurgical approaches.\u003c/p\u003e \u003cp\u003eWe found an association of PINI mortality with age\u0026thinsp;\u0026gt;\u0026thinsp;60 years, diabetes or immunodepression in the multivariate analysis. These variables are known to be associated with an increased risk of developing a neurosurgical infection after craniotomy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However we could not demonstrate an association of PINI cure or mortality with male gender, length of hospital stay before surgery, duration of operation (\u0026gt;\u0026thinsp;4 hours), number of operations (\u0026gt;\u0026thinsp;1), or nontraumatic reason of surgery that other authors found [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Probably the relatively small size of our cohort limited the statistical analysis. In spite of the lack of association of CSF leakage with PINI mortality in our study, previously reported by others, an association of post-neurosurgical meningitis, favored by the CSF-leakage, with mortality was demonstrated in our work [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost of the microorganisms isolated from pus drainage, blood or CSF of our patients, mainly \u003cem\u003eStaphyloccosus spp\u003c/em\u003e were similar to those identified in previous series [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Interestingly more than one third of isolates of our PINI cases were Gram negative bacilli in a number much higher than previous works. This fact might suggest that in those cases Gram negative bacilli from the hospital flora colonized the neurosurgical wounds enhancing PINI.\u003c/p\u003e \u003cp\u003eOverall 16.8% of our PINI patients did not receive pre-operative antimicrobial prophylaxis. One of the explanations for this fact might be that almost one third of the cases underwent urgent surgery due to vascular or trauma reasons. Buffet-Bataillon et al in a study of 883 patients recruited in the period 2008\u0026ndash;2009 in France found that emergence neurosurgical procedures were associated with an increased risk of surgical site infections [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Antibiotic prophylaxis decreased infection rate from 97\u0026ndash;5.8% in 4578 patients undergoing craniotomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Mollman and Haines performed a case-control analysis on 9,202 patients with neurosurgical wounds and found that antibiotic prophylaxis was associated with a decreased rate of surgical site infection [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, we could not observe a worse evolution in those PINI patients that did not receive pre-operative antimicrobial prophylaxis. Furthermore an increased PINI cure rate or increased survival in our patients that were receiving antimicrobial therapy previously to neurosurgery was not found, either.\u003c/p\u003e \u003cp\u003eThere are not standard antimicrobial guidelines for PINI treatment [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore many antimicrobials in monotherapy and multiples antibiotic combinations were used to treat PINI in our series precluding the statistical analysis of these variables. Although we observed a significant association of some combined initial IV antimicrobial regimens, some of them containing vancomycin (carbapenem\u0026thinsp;+\u0026thinsp;vancomycin, amoxicillin/clavulanate\u0026thinsp;+\u0026thinsp;vancomycin) with PINI cure when compared to the combination of carbapenems\u0026thinsp;+\u0026thinsp;aminoglycoside in the univariate analysis, the instauration of a combined antimicrobial therapy was nor associated with cure in the multivariate analysis (p\u0026thinsp;=\u0026thinsp;0.202). Surprisingly a combined initial IV antimicrobial regimen was significantly associated with higher mortality (p\u0026thinsp;=\u0026thinsp;0.001). This unexpected finding could be explained by the fact that patients with more severe PINI were started on empiric combined IV antimicrobial regimens due to their serious clinical situation more frequently than those with minor PINI that were put initially on IV antimicrobial monotherapies.\u003c/p\u003e \u003cp\u003e Our results of a median of 3 weeks of IV antimicrobial therapy for PINI shorten to a half the guidelines made by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) that recommend 6\u0026ndash;8 weeks of IV antimicrobials for aspirated or conservatively treated brain abscesses. However only 62 patients of our study (38.3%) had a CNS abscess and 19.8% had other had other infections such as scalp\u0026acute;s (19.8% ) that did not require long IV antimicrobial therapy. The same ESCMID guidelines do not recommend neither early transition to oral antimicrobials nor oral consolidation treatment after \u0026gt;\u0026thinsp;6 weeks of IV antimicrobials for brain abscess. Extended oral antimicrobial therapy after hospital discharge was significantly associated with cure in our PINI cases .This oral therapy was combined in one third of cases and was based on single or combined quinolones regimens. Quinolones cross easily the blood-brain barrier and through the bacterial-generated biofilm and are ideal antimicrobials to treat PINI especially with foreign body devices such as cranioplasty grafts. [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding PINI outcome four fifths of our PINI patients cured, 11.8% relapsed and one fourth died but only 6.8% due to PINI. Bodilsen et al in a recent meta-analysis found a relapse or recurrence rate of 3.4% in children and adults with brain abscesses treated with IV antimicrobials for \u0026gt;\u0026thinsp;6 weeks and surgical pus drainage [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However 26% of our PINI patients had cranioplasty infections or skull osteomyelitis with a very high relapse rate, higher than CNS abscess The mortality rate due to PINI in our cases, in whom one fifth was immunodepressed and one fourth had comorbiditites was slightly higher than the 4.7% reported by Korinek et al in France in a large prospective cohort of 383 PINI patients after 6243 consecutive craniotomies. However when these authors considered only those patients with postsurgical meningitis the mortality raised to 13.7% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A fatality rate of 4.4% was observed in 45 Indian patients with subdural empyema treated with pus drainage and broad-spectrum antibiotics [20]. Bodilsen et al in a recent meta-analysis found a fatality rate of 9% in children and adults with brain abscess treated with aspiration or excision [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main strength of this work relies on its focus on PINI antimicrobial therapy, a point neglected by most of the previous studies on this topic, the relatively large sample size and the elevated number of parameters assessed, which allowed to adjust for and minimize the effect of confounders in the uni and multivariate analysis. Limitations include those common to retrospective studies, the long time needed, 9 years, for closing the study due to the interfering COVID-19 pandemia, the absence of a unified antimicrobial treatment protocol for PINI, which would allow the evaluation of the responses to the same treatment, and the variability characteristic of multicenter studies, particularly regarding procedural and management aspects. However, as we have mentioned before, currently no single or widely accepted treatment protocol exists considering the great diversity of clinical and microbiological issues related to PINI, and the multicenter character of the study allows the evaluation of the real clinical practice across our country, minimizing potential biases from a single institution.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe conclude that an extended 6 weeks sequential IV for 3 weeks and oral antimicrobial therapy for other 3 weeks in addition to neurosurgical correction increases PINI cure rate and might improve patients\u0026acute; survival .\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI :confidence interval; CNS: Central Nervous System; C-RP: C-reactive protein; CSF: Cerebrospinal fluid; \u0026nbsp; CT:computerized tomography; ESR: erythrocyte sedimentation rate; GCS: Glasgow Coma Scale; HR: hazard rate; ICU: Intensive Care Unit; IV: intravenous; ID: Infectious Diseases; \u0026nbsp;MRI: magnetic resonance imaging; OR :Odds ratio; PINI : Postoperative intracranial neurosurgical infections\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Infectious Diseases Working Group of the Spanish Society of Internal Medicine (SEMI) for help promoting and funding this study. This organization had no role in the study design, collection,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;:This was an observational study, using anonymized data, in which the patients underwent routine clinical care for PINI, without any change in its management or specific determinations or procedures. Therefore, no formal written informed consent was obtained from the patients. The Research Ethics Committee of the Principality of Asturias granted a formal waiver of ethical approval for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The Infectious Diseases Working Group of the Spanish Society of Internal Medicine (SEMI) supported and funded this study\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.V., H.G., S.S.-D., E.A.-D.;N.C.-A., A.G.-R.,M.V.M., J.M.G., J.A., M.A.S., X.G.-C., C.D., and M.B. recruited patients and collected the data, JC designed the study data file, VC did the statistical analysis of the data and VA designed the study, recruited patients, collected data and wrote the manuscript. All authors have read and approved the final version manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKorinek AM, Golmard JL, Elcheick A, Bismuth R, van Effenterre R, Coriat P, et al. Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4,578 patients. Br J Neurosurg. 2005;19:155\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02688690500145639\u003c/span\u003e\u003cspan address=\"10.1080/02688690500145639\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErman T, Demirhindi H, G\u0026ouml;\u0026ccedil;er AI, Tuna M, Ildan F, Boyar B. 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Spectrum of intracranial subdural empyemas in a series of 45 patients: current surgical options and outcome. Neurol India. 2004;52:346\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"neurosurgery, intracranial infections, antimicrobial therapy, cure, mortality","lastPublishedDoi":"10.21203/rs.3.rs-4946614/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4946614/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative intracranial neurosurgical infections (PINI) complicate \u0026lt; 5% neurosurgeries. Scarce attention was dedicated to the extension and characteristics of its antimicrobial management considering their high morbidity, not negligible mortality, delayed hospital stay and increased healthcare costs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analyzed retrospectively (2014–2023) 162 PINI from eight Spanish third-level academic hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElective clean craniotomies after tumor or vascular causes were the leading procedures. Epidural abscess (24.7%), scalp infections (19.8%), postsurgical meningitis (16.7%) and cranioplasty infections (16.7%) were the most frequent PINI. \u003cem\u003eStaphylococcus spp\u003c/em\u003e (43.9%) and Gram negative bacteria (38.6%) were the predominant isolates. Overall 85.2% patients underwent pus drainage, mostly by craniotomy (40.3%). Interestingly 34% were already receiving antibiotics for extracranial infections before developing PINI while 16.8% did not receive pre-operative antibiotic prophylaxis. In total 77.2% patients started a combined intravenous (IV) antimicrobial therapy, of which 85.2% switched after 5 days to a second-line IV antibiotic regimen, in 41.3% cases combined, after pus culture results, for a median of 21 days. Overall 61.1% patients continued on oral antimicrobials after hospital discharge, 30.3% as a combined regimen, for a median of 42 days. Complete cure was obtained in 81.5% cases, while 11.1% relapsed, 7.4% failed to cure and 6.8% died after PINI complications. In the multivariate analysis oral antimicrobial therapy after hospital discharge (p = 0.001) was significantly associated with PINI cure with a marginal positive effect on survival (p = 0.066) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conclude that an extended 6 weeks sequential IV and oral antimicrobial therapy in addition to neurosurgical correction increases PINI cure rate and might improve survival\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number: not applicable\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Extended sequential intravenous and oral antimicrobial therapy improves cure rate in postoperative intracranial neurosurgical infections. A Spanish multicenter retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-20 11:51:18","doi":"10.21203/rs.3.rs-4946614/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-22T12:10:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-22T05:54:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-22T05:54:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-08-20T16:48:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cdabe30d-5f23-4d30-bfbc-e103b950a39c","owner":[],"postedDate":"September 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T16:02:20+00:00","versionOfRecord":{"articleIdentity":"rs-4946614","link":"https://doi.org/10.1186/s12879-024-10204-7","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-11-26 15:57:34","publishedOnDateReadable":"November 26th, 2024"},"versionCreatedAt":"2024-09-20 11:51:18","video":"","vorDoi":"10.1186/s12879-024-10204-7","vorDoiUrl":"https://doi.org/10.1186/s12879-024-10204-7","workflowStages":[]},"version":"v1","identity":"rs-4946614","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4946614","identity":"rs-4946614","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}