ANTIBIOTIC PROPHYLAXIS IN CRANIAL BASE SURGERY Ricardo L. Carrau, MD, Carl Snyderman, MD, Ivo P. Janecka, MD, Laligam Sekhar, MD, Chandra Sen, MD, and Frank D’Amico, PhD

The role of perioperative antibiotic prophylaxis was investigated in 95 patients undergoing 100 clean-contaminated cranial base surgeries. A variety of antibiotic regimens were employed. Potential risk factors for local infection were analyzed. Seven patients (7%) developed infections at the surgical site (meningitis, intracranial abscess, cellulitis/abscess, and osteomyelitis). Antibiotic prophylaxis for 24 hours or less was associated with a significantly increased risk of infection (p < 0.04). Prolonged antibiotic prophylaxis (>48hours) was not more efficacious than prophylaxis for 48 hours. The surgical approach, type of reconstruction, duration of surgery, and use of drains were not significantly correlated with wound infection. The risk of intracranial infection following cranial base surgery is low despite the presence of bacterial contamination intraoperatively. Broad-spectrum coverage of gram-positive and gram-negative organisms for at least 48 hours is recommended. Attention to surgical technique is important in preventing infectious complications. HEAD & NECK 1991;13:311-317.

T h e role of perioperative antibiotic prophylaxis in the treatment of patients undergoing cranial base surgery has not been established. Cranial base surgery is predominantly performed for in~

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From the Department of Otolaryngology (Drs. Carrau, Snydenan. and Janecka), Eye and Ear Institute, Pittsburgh, Pennsylvania; Department of Neurosurgery (Drs. Sekhar and Sen), Presbyterian University Hospital, Pittsburgh, Pennsylvania; and Department of Mathematics (Dr. D’Amico). Duquesne University, Pittsburgh, Pennsylvania. Address reprint requests to Dr. Snyderman at the Department of Otolaryngology, Eye and Ear Institute, 203 Lothrop Street, Suite 500, Pittsburgh, PA 15213. Accepted for publication November 14, 1990. CCC 0148-6403/91/040311-07 $04.00 6 1991 John Wiley & Sons, Inc.

Role of Antibiotics in Cranial Base Surgery

tracranial andlor extracranial neoplasms in close promixity to or involving the base of the skull. These surgeries require approaches which frequently result in large defects of the cranial base. Contamination of the intracranial contents by the flora of the upper aerodigestive tract is a common occurrence. Unless anatomical separation of the cranial cavity and the upper aerodigestive tract is restored, continued contamination of the cerebrospinal fluid (CSF) with resultant meningitis may occur. Due to the extensive nature of the surgery and the amount of bacterial contamination intraoperatively, these patients represent one of the highest risk groups for postoperative would infections in surgery. The potential morbidity of a postoperative wound infection is great and includes the development of meningitis, brain abscess, and osteomyelitis. There have been no adequate trials examining the role of perioperative antibiotic prophylaxis in this patient population. The purpose of this study was to determine the risk of wound infection in patients undergoing cranial base surgery. Factors which may have an impact on the infection rate (patient and disease characteristics, treatment factors, and antibiotic regimen) were retrospectively examined. METHODS

The role of perioperative antibiotic prophylaxis was investigated retrospectively in 95 patients undergoing 100 cranial b&e surgeries from 1987 to 1989. All surgeries involved exposure of the

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cranial cavity to the bacterial flora of the aerodigestive tract and/or paranasal sinuses. The study population consisted of 48 females (51%) and 47 males (49%) with a median age of 45 years (range 6-81 years). Six patients (6%) received antibiotic therapy preoperatively within 1month of the cranial base operation. Seven patients (7%)presented with a CSF leak preoperatively. Two other patients subsequently required a second operation for treatment of a postoperative CSF leak. The remaining 86 patients were treated for a variety of malignant (56%) and benign (44%) neoplasms. Five patients required staged procedures. Surgical approaches were classified as anterior, lateral, anterolateral, or posterior, since anterior and anterolateral approaches were felt to have the greatest potential for bacterial contamination and subsequent wound infection. The extent of surgical exposure, as well as methods of reconstruction, were recorded. The use of scalp and lumbar spinal drainage was also noted. Antibiotic prophylaxis was administered according to the preference of the attending surgeon. Due to the number of different surgeons and clinical services, a large variety of antibiotic regimens were employed. All antibiotics were started at the beginning of the procedure prior to the skin incision. Irrigation with bacitracin (50 mg/mL) or streptomycin (50 pg/mL) was employed intraoperatively. A surgical wound infection was diagnosed on the basis of the presence of purulent secretions. Patients with fever, wound erythema, tenderness, swelling, or positive cultures in the absence of pus were not considered infected. The diagnosis of meningitis required the presence of classical diagnostic criteria of elevated protein, leukocytosis, and identification of bacteria by Gram stain or culture in the CSF. Urinary tract infections, pneumonia, and other systemic infections were diagnosed in the presence of fever, positive cultures, and the need for intravenous antibiotics as determined by the primary physician. Variables were dichotomized for univariate analysis and Fisher’s exact probability test was used for significance testing. Multiple logistic regression was performed using Statistix software on variables that were significant ( p < 0.05) or clinically thought to be important. RESULTS

Cranial base lesions were managed through anterior (36%),lateral (17%), anterolateral (46%),

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Role of Antibiotics in Cranial Base Surgery

or posterior (1%)approaches. The paranasal sinuses or mastoid antrum were violated in 91% of the surgeries. Transgression of the dura, inadvertently, when elevating the craniotomy bone flaps, or as required for the resection, occurred in 90% of the cases. The dura was repaired primarily in 23 of 90 (26%)of the patients or with a fascia graft in 67 of 90 (74%)cases. Vascularized flaps were used for reconstruction in 93% of the cases: temporalis muscle transposition (56%), pericranial/galeal-pericranialflap (35%),free microvascular flap (18%), sternocleidomastoid musMultiple vascucle flap (I%), and scalp flap (1%). larized flaps were used in 11 patients. Nonvascularized tissue grafts including fat (12 of 100) and free bone grafts (5 of 100) were less commonly used. The average duration of surgery was 9.8 hours (range 3.5- 26 hours). Patients required an average of 3.8 U of blood per surgery (range 0-13 U). Closed suction drains were used in 94% of the cases. Drains were discontinued after an average of 3.3 days (range 1-12 days). Lumbar spinal drains were used in 83% of the cases. Drainage was maintained for an average of 1.7 days (range 1-6 days). Nasal packing was not employed in any of the operations. The most commonly used antibiotic regimens were cefuroxime (38 of 1001, first-generation cephalosporin and vancomycin (18 of loo), firstgeneration cephalosporin and aminoglycoside (13 of loo), aminoglycoside and vancomycin (5 of 1001, and triple antibiotic therapy (13 of 100). Other combinations or single antibiotic regimens were used in 13% of the surgeries. Antibiotic prophylaxis was continued for a mean of 3.7 days (range 1- 12 days). Eight patients received antibiotic prophylaxis for 24 hours or less. Twentyone patients received antibiotic prophylaxis for 24 to 48 hours; 71 patients received antibiotic prophylaxis for greater than 48 hours. Seven patients developed an infection at the surgical site: meningitis in 2 patients, an intracranial abscess in 1 patient, wound cellulitidabscess in 3 patients, and osteomyelitis in 2 patients. Of these patients, l developed cellulitis with subsequent osteomyelitis and 1developed a wound infection and meningitis. Multiple organisms were cultured from sites of infection: Pseudomonas (31, Neisseria (11, Staphyloccoccus aureus (4), anaerobic mixed flora (11, and B-Streptococcus (1). Other infectious complications included otitis media (2%), pneumonia (5%), urinary tract infection (4%), tracheitis

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(2%), sepsis (1%), oral cellulitis (1%), and peristoma1 gastrostomy cellulitis (1%). A detailed analysis of the 7 patients with surgical wound infections was performed. The average age was 40 years (range 19-59 years). Six of the patients had surgery performed for neoplasms, of which 3 were adenoid cystic carcinomas; one had a CSF leak. Three patients had received radiotherapy preoperatively. An anterior or anterolateral approach was employed in 6 patients. The average duration of surgery was 13.1 hours (range 9-26 hours). Opening of the dura and sinuses occurred in all cases. Pericranial grafts were required for dural closure in 6 patients. The cranial base defect was reconstructed with regional vascularized tissues (pericranial flap, temporalis muscle) in 5 patients, and a microvascular free flap (latissimus dorsi) in l patient. Scalp drains were continued for an average of 2.9 days postoperatively; spinal drains were continued for an average of 2 days. Nasal packing was not employed in any of the cases. A variety of antibiotic regimens were employed, including a single cephalosporin (cefuroxime) and triple antibiotics. The duration of antibiotic prophylaxis ranged from 1 to 6 days. Two of the patients had concurrent tracheostomies. Only 1 patient had evidence of a transient CSF leak postoperatively. Predisposing factors for the development of infection were identified in 5 patients and included scalp necrosis, epidural fluid collections (hematoma, CSF), dead space, and CSF leak. Univariate analysis of potential risk factors for the development of infection at the surgical site is presented in Tables 1-3. This analysis suggests that the duration of perioperative antibiotic prophylaxis has a statistically significant

Table 1. Univariate analysis of infection.' Patient characteristics

Infection rate

%

3/47 4/53

7 8

4151 3/49

8

016 7/94

0

Age

40 years Sex Male Female Previous infection Yes No

6

8

'Infection of the surgical site (meningitis, intracranial abscess, osteomyelitis. wound cellu/itis/abscess).

Role of Antibiotics in Cranial Base Surgery

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Table 2. Univariate analysis of infection.' ~

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Disease characteristics Diagnosis CSF leak Squamous cell carcinoma Adenoidcystic carcinoma (p = 0.0001) Adenocarcinoma Meningioma Angiomatous tumors Sarcomas Neurilemmomas Chordomas Other Neoplasm Benign Malignant Primary site Sphenoid bone (p = 0.1) Nasopharynx Frontal sinuslbone Nasal cavitylcribiform plate Maxillalorbit Temporal bone lnfratemporal fossa Ethrnoid sinus Posterior fossa Tracheotomy Yes No Previous CSF leak Yes No

Infection rate

%

1 I9

11 0 50 0 0 0 14

0120

316 014 0113 017 2/14 119 015 018

11 0

0

1/38 5/48

3 10

4/32 015 1 /7 0110 1 /9 011 7 1/15 013 012

13 0 14 0 11 0 7 0 0

014 7/96

0 7

1 /7 6/93

14 6

'Infection of the surgical site (meningitis, intracranial abscess, osfeomyelitis, wound cellulitislabscess).

effect on the incidence of postoperative wound infection. The incidence of local infection in patients receiving prophylactic antibiotics for 24 hours or less (2 of 8) was significantly greater than those receiving antibiotics for more than 24 hours (5 of 92,p = 0.04).The incidence of local infection in patients receiving antibiotic prophylaxis for 24 to 48 hours (0 of 21) was not significantly different from those receiving antibiotics for more than 48 hours (5 of 71,p > 0.1). No other risk factors were found to be significant except for a diagnosis of adenoid cystic carcinoma. Three of six patients undergoing surgery for adenoid cystic carcinoma developed local wound infections (p < 0.0001). Multiple logistic regression was performed using 5 variables: diagnosis, site of origin, duration of surgery, duration of wound drains, and duration of antibiotic prophylaxis. Patients receiving antibiotic prophylaxis for less than or equal to 24 hours and with a histologic diagnosis

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of adenoid cystic carcinoma were most likely to suffer a wound infection.

Table 3. Univariate analysis of infection.’ Infection rate

(”/.I

3/36 1/17 3/46 011 6/82 1/18

8 6 7 0 73 6

7/90 0110

8 0

7/91 019

8 0

1I23

6/67

4 9

7/89 0111

8 0

6/93 117

6 14

115 6/95

20 6

117 2/46 9/45 2/17 011 o/1

14 9 12 0 0

Vascularized tissue Nonvascularized tissue Use of lumbar drains Yes 1 day No Use of wound drain Yes 3 days No Positive margins Yes No Duration of surgery (p = 0.1) 5 8 hours >8 hours Duration of antibiotic prophylaxis 24 hours >24 hours

5/81 1/12

6 8

5/83 2/51 3/32 2117

6 4 10 12

7/94 5/57 2/37 016

7 9 5

2/27 416 I

7

0133 7/67

0 10

2/8 5/92

24-48 hours >48 hours Antibiotics Cefuroxime First-generationcephalosporin and vancomycin First-generationcephalosporin and aminoglycoside Arninoglycoside Triple antibiotics Other

0121 517 1

25 5 (p = 0.04) 0 7

2/38 0115

5 0

1/17

6

115 2113 1/12

20 15 8

3/47 4/53

6 8

Treatment factors Surgical approach Anterior Lateral Anterolateral Posterior Anterior and anterolateral Other Opening of dura Yes No Opening of sinuses Yes No Dura repair Primary Grafts Blood transfusion Yes No Reconstructive flap Yes No Use of bone grafts Yes No Reconstructive flaps None Temporalis muscle Galeal-pericranial, pericranial Free rnicrovascular Sternocleidomastoid muscle Scalp

1 antibiotic >1 antibiotic

4

0 7

‘Infection of the surgical site (meningitis, intracranial abscess, osteomyelitis, wound celIulitis/abscess).

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Role of Antibiotics in Cranial Base Surgery

DISCUSSION

The risk of postoperative wound infection is related to 4 factors: (1)virulence of the contaminating organism, (2) host susceptibility,’ (3)the milieu at the surgical site, and (4) degree of bacterial ~ o n t a m i n a t i o n . ~ Perioperative ,~ antibiotic prophylaxis prevents wound infection by improving the host’s ability to fight the infectious organism and dimnishing the virulence. The other two factors are largely related to surgical technique. Parenteral antimicrobial prophylaxis is recommended when the risk of infection is high, or when the development of a n infection is associated with severe or life-threatening complications.’ The sequelae of a wound infection following head and neck surgery include loss of soft tissue and bone, loss of reconstructive flaps, aggravation of cosmetic defects, need for intravenous antibiotics, life-threatening septicemia, and increased length and cost of hospitalization. The potential morbidity of a wound infection following cranial base surgery is greatly intensified due to the extensive soft tissue and bone dissection and the life-threatening potential of an intracranial infection. Although the presence of a “normal” bacterial flora in the paranasal sinuses is c o n t r ~ v e r s i a l , ~ - ~ the upper aerodigestive tract (orohasopharynx) harbors aerobic and anaerobic gram-positive and -negative bacteria with concentrations as high as 10’~organisms/mL of secretion^.^ The surgical literature supports the need for perioperative prophylaxis in clean- contaminated head and neck surgery.778Johnson et al.7 found that 80% of patients undergoing clean-contaminated head and neck surgery not treated with antibiotic prophylaxis experienced postoperative wound infection, whereas only 15% of the patients receiving antibiotics experienced a surgical wound infection. The neurosurgical literature suggests that patients treated with perioperative antibiotic prophylaxis suffer a lower rate of wound infections. Blomstedt and Kytta’ and van Ek et a1.l’ demonstrated that patients treated with antibiotic prophylaxis suffered a significantly lower rate of wound infection in prospective randomized, double-blind studies employing vancomycin and cloxacillin regimens, respectively. It is im-

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portant to note, however, that these studies were based on clean neurosurgical procedures. The contaminated nature of craniofacial surgery burdens the design of a double-blind study employing a placebo. The rate of wound infection after skull base surgery in patients receiving antibiotic prophylaxis varies from 0% to 23%. Cheesman et a1.l’ reported no wound infections in their experience with 60 patients undergoing anterior craniofacial resection. Gransden et al.l2 reported 11 cases of meningitis in 114 (9.6%) patients undergoing transphenoidal pituitary tumor resection. Sundaresan and Shah13 reported local wound infections in 7 of 30 (23%) patients after resection of anterior cranial base tumors. David and Cooter14 reported a 6.5% incidence of infection after 170 transcranial operations with an increased incidence of 23.5% for their adult population. Our series demonstrates that patients receiving perioperative antibiotic prophylaxis for cranial base surgery have a low risk of intracranial infection despite the presence of bacterial contamination. The type and duration of antibiotic prophylaxis are controversial. Antimicrobial prophylaxis should be initiated before wound contamination to be maximally effective and continued for 24 to 36 hours postoperatively. Johnson et al.15 and Fee et a1.16 have demonstrated that 24hour prophylaxis with a broad-spectrum antibiotic is suMicient to prevent surgical wound infections in clean-contaminated head and neck surgery. Review of the neurosurgical literature reveals prophylactic antibiotics are used for periods from 24 hours or “until the drains come Other centers performing cranial base surgery report the empirical use of antibiotic ~ hours,13 ~ , ~ ~ or until prophylaxis for 48 h ~ u r s ,72 the drains are removed.18 Statistical analysis of our data suggests that the use of perioperative antibiotic prophylaxis for 24 hours or less is associated with a higher infection rate (p = 0.041, whereas an incidence of local wound infection in patients receiving antibiotics for 48 hours was not significantly different than patients receiving prophylaxis for greater than 48 hours (p > 0.1).These findings suggest that antibiotic prophylaxis in patients undergoing cranial base surgery should be continued for at least 48 hours postoperatively. The increased duration of antibiotic prophylaxis may be necessary due to the extensive nature of the surgery or continued contamination of the surgical site and CSF by bacterial flora postopera-

Role of Antibiotics in Cranial Base Surgery

tively. This is supported by the observation that many patients have transient (2-3 days) CSF leaks in the early postoperative period. The bacteriology of these wound infections supports the need for broad-spectrum antibiotic coverage. Most series report infections caused by Staphylococcus aureus, Staphylococcus epidermidis, coliforms, Hemophilus influenza, and anaerobes. In order to be effective, antibiotic prophylaxis should cover most common skin and aerodigestive tract pathologens. In order to achieve this, a combination of antibiotics is frequently employed. We did not find a statistically significant difference, however, between patients receiving a single broad-spectrum agent (cefuroxime) and those receiving a combination of antibiotics. The ideal antibiotic regimen for cranial base surgery should have the following characteristics: (1)a single antibiotic agent, (2)good CSF penetration in the absence of infection, (3) in vitro and in vivo activity against common flora of the upper aerodigestive tract, (4)absence of significant morbidity, ( 5 ) minimal cost, and (6)a convenient dosing schedule. Cefuroxime was chosen as a single agent because of its broad-spectrum activity against coliforms, Hemophilus influenza, Staphylococcus, and Pneumococcus. It appears to penetrate the blood-brain barrier as well as ampicillinlg and has been demonstrated to be as effective as ampicillin and chloramphenicol for the treatment of bacterial meningiOther cephalosporins, however, may be better suited for antibiotic prophylaxis in this patient population. The importance of other factors in the development of postoperative wound infection has been stressed by various authors. Robbins et al.3 analyzed 400 patients undergoing head and neck surgery. This study included clean (123 of 400), clean- contaminated (268 of 4001, and contaminated (9 of 400)surgeries. The stage of the tumor (T and N), duration of surgery, type and complexity of surgery, use of reconstructive flaps, blood replacement, use of drains, use of nasogastric tubes, and the presence of a tracheotomy contributed significantly to an increased incidence of postoperative wound infection. Using logistic regression analysis, they demonstrated that the type of surgery, the choice of antibiotics, the presence of concomitant disease, and the N stage represented the combination of factors most predictive of postoperative wound infection. Brown et a1.’ studied 305 patients undergo-

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ing major clean-contaminated head and neck surgery. Patients with stage IV disease and those reconstructed with pedicled myocutaneous flaps experienced a significantly increased incidence of postoperative wound infection. Weight loss, diabetes mellitus, prior radiotherapy, or the presence of a tracheotomy were not found to significantly alter the rate of infections. They were able to identify errors in surgical technique in 10 of 17 patients with postoperative wound infections. Analysis of the patients in our series with surgical wound infections suggests that an anterior or anterolateral approach may be a predisposing factor. This is not surprising, because these approaches are often associated with large dural and cranial base defects with extensive contamination by the flora of the nasopharynx. Preoperative irradiation may also be a risk factor. Radiotherapy may delay wound healing, thus prolonging CSF contamination postoperatively, and compromise the vascularity of local tissues (galedpericranium) used to reconstruct the cranial base defect. The major factor contributing to the development of a surgical wound infection after cranial base surgery continues to be errors in surgical technique (eg, necrotic tissue, dead space, fluid collections). The basic principles of surgery cannot be overemphasized. Adequate preparation

and draping, debridement of necrotic tissue, gentle handling of tissue, obliteration of dead spaces, use of vascularized tissue for reconstruction, and separation of the cranial cavity from the aerodigestive tract are of utmost importance. The pericranial scalp flap is a versatile and reliable method for the isolation of the cranial cavity from the aerodigestive tract and is associated with minimal morbidity.21p22 Other factors associated with wound infections (CSF leak, complexity and duration of surgery, extent of resection, administration of blood products, and use of drains) were not found to be significant @ >0.1). Due to the multifactorial nature of wound infections, statistical sigdicance may be only achieved with a larger study population. The reason for the increased infection rate in our series in patients with a diagnosis of adenoid cystic carcinoma is unclear. This may be related to a multitude of factors, such as extent of surgery, surgical approach, positive pathologic margins, etc., working in concert. Further studies are necessary to determine the most effective antibiotic regimen with the least morbidity for the perioperative prophylaxis of patients undergoing cranial base surgery. Presently, our data support the use of a single broad-spectrum cephalosporin, administered at the beginning of the operation and continued for 48 hours postoperatively.

REFERENCES 1. Gamer JS. CDC guideline for prevention of surgical wound infections, 1985. Infect Control 1986;7:193-200. 2. Brown BM, Johnson JT, Wagner RL. Etiologic factors in head and neck wound infection. Lawngoscope _ _ 1987;97:587-590. 3. Robbins KT, Favrot S, Hannah D, Cole R. Risk of wound infection in Datients with head and neck cancer. Head & Neck 12:143'-148, 1990. 4. Brook I. Aerobic and anaerobic bacterial flora of normal maxillary sinuses. Laryngoscope 1981;91:372-376. 5. Mathog RH, Crane LR, Nowek GS. Antimicrobial therapy following head and neck trauma. In: Johnson JT, ed. Antibiotic therapy in head and neck surgery. New York Marcel Dekker, 1987:31-50. 6. Wald ER, Dachling P. Diagnosis and treatment of sinusitis and its complications. In: Johnson JT, ed. Antibiotic therapy in head and neck surgery. New York Marcel Dekker, 1987:125- 149. 7. Johnson JT, Myers EN, Thearle PB, Sigler BA, Schramm VL. Antimicrobial prophylaxis for contaminated head and neck surgery. Laryngoscope 1984;94:46-51. 8. Johnson JT, YTJ VL. Antibiotic use during major head and neck surgery. Ann Surg 1988;207:108-111. 9. Blomstedt BC, Kytta J. Results of a randomized trial of vancomycin prophylaxis in craniotomy. J Neurosurg 1988;69216-220. 10. van Ek B, DQkmans BA, VanDulken H, VanFurth R.

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Role of Antibiotics in Cranial Base Surgery

Antibiotic prophylaxis in craniotomy: a prospective double blind placebo-controlled study. Scand J Infect Dis 1988;20633-639. 11. Cheesman AD, Lund VJ, Howard DJ.Craniofacial resection for tumors of the nasal cavity and paranasal sinuses. Head Neck Surg 1986429-436. 12. Gransden WR,Path MRC, Wickstead M, Eykin SJ. Meningitis after transsphenoidal excision of pituitary tum o w . J Laryngol Otol1988;102:33-36. 13. Sundaresan N, Shah JD. Craniofacial resection for anterior skull base tumours. Head Neck Surg 1988;10219224. 14. David DJ, Cooter RD. Craniofacial infection in 10 years of transcranial surgery. P l a t Reconstr Surg 1987;80:213-223. 15. Johnson JT,Schuller DE, Silver F, Gluckman JL, Newman RK, Shagets FW, et al. Antibiotic prophylaxis in high risk head and neck surgery: One day vs. five day therapy. Otolaryngol Head Neck Surg 1986;95:554557. 16. Fee WE,Glenn M, Handen C, Hopp ML. One day vs. two days of prophylactic antibiotics in patients undergoing major head and neck surgery. Laryngoscope 1984;94612-615. 17. Savitz MH, Katz SS. Prevention of primary wound infection in neurosurgical patients a 10 year study. Neurosurgery 1986;18:685-688.

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18. Conover MA, Kaban LB, Mulliken JB. Antibiotic prophylaxis for major maxillocraniofacial surgery. J Oral Muxillofac Surg 1985;43:865-869. 19. Report from a Swedish Study Group. Cefuroxime vs. ampicillin and chloramphenicol for the treatment of bacterial meningitis. Lancet 1982;1:295-299. 20. Marks WA, Stutman HT, Marks MI, et al. Cefuroxime vs. ampicillin plus chloramphenicol in childhood bacte-

Role of Antibiotics in Cranial Base Surgery

rial meningitis: a multicenter randomized controlled trial. J Pediutr 1988;109:124-130. 21. Price JC, Loury M, Carson B, Johns ME. The pericranial flap for reconstruction of anterior skull base defects. Laryngoscope 1988;98:1159-1164. 22. Snyderman CH, Janecka IP, Sekhar LN, Sen CN, Eibling DE. Anterior cranial base reconstruction: Role of galeal and pericranial flaps. Laryngoscope 1990;100:607614.

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Antibiotic prophylaxis in cranial base surgery.

The role of perioperative antibiotic prophylaxis was investigated in 95 patients undergoing 100 clean-contaminated cranial base surgeries. A variety o...
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