Antibiotic Use in Endoscopic Endonasal Pituitary and Skull Base Surgery

Introduction: Infectious complications of endoscopic endonasal transsphenoidal surgery (EETS) include meningitis and sinusitis. Current rates in the literature are 0.5 to 14% for meningitis and 3.6 to 9.6% for sinusitis. Despite the utility of prophylactic antibiotics, there remains a need for improved evidence-based guidelines on the optimal dosage and timescale upon which to administer antibiotics. We analyze the infectious outcomes, along with potential risk factors contributing to infectious outcomes, among a large cohort of patients undergoing EETS.

Design: Retrospective review.

Setting: Tertiary care hospital.

Participants: Consecutive adult patients undergoing EETS from July 2018 to July 2020.

Methods and Main Outcome Measures: Patient, tumor, and surgical characteristics were collected, along with postoperative infection rates. Multivariate logistic regression determined the variable(s) independently associated with infectious outcomes.

Results: A total of 132 patients underwent EETS. Most patients had pituitary adenomas (80%) and underwent primary surgery (81%). Average age was 46 years (SD ± 16). There was notable presence of comorbidities, including obesity or body mass index ≥30 (43%), diabetes (22%), and immunosuppression (11%), which included chronic steroid or immunosuppressant use, as well as history of organ transplant, human immunodeficiency virus, or end-stage renal disease. Intraoperatively, most patients received cefazolin (95%), while 4% received clindamycin. Operations lasted an average of 2.7 hours (SD ± 1.0). Fifty-three patients (40%) experienced an intraoperative cerebrospinal fluid (CSF) leak, with 8% having a grade 3 leak. Following EETS, all patients were admitted to the hospital for routine monitoring. Length of stay (LOS) averaged 2.5 days (SD ± 2.1). Nearly all patients (99%) received inpatient postoperative antibiotics, with 78% receiving cefazolin, 17% receiving cephalexin, 3% receiving clindamycin, and 2% receiving other antibiotics. Three patients (2%) developed a postoperative CSF leak requiring return to the operating room for repair. While inpatient, no patients developed meningitis, urinary tract infection, or sinusitis. Three patients (3%) developed pneumonia, while one patient (1%) developed cellulitis at a peripheral intravenous line. One patient (1%) developed an allergy to cephalexin, requiring conservative management with antihistamines. After adjustment for patient characteristics and comorbidities and operative factors, presence of postoperative infectious complications were independently associated with increased LOS (β = 3.7 days, p = 0.001). On discharge, most patients were given antibiotics (95%). These included cephalexin (86%), clindamycin (6%), or Augmentin (3%). The most common reason a patient did not receive discharge antibiotics was due to LOS > 7 days. On average, patients had their first follow-up 19 days (SD ± 35) after surgery and second follow-up 63 days (SD ± 55) after surgery. After discharge, no patients developed meningitis. 2% of patients developed sinusitis and 2% of patients developed an allergy to their antibiotic, within 30 days after surgery.

Conclusion: We report low rates of infectious complications and antibiotic intolerance within our cohort undergoing EETS, despite presence of a heavy burden of comorbidities, compared with reported findings in the literature. These findings support our standardized perioperative antibiotic regimen: cefazolin for 24 hours, then cephalexin for seven days following surgery (clindamycin if penicillin/cephalosporin-allergic). Furthermore, we report an independent association between LOS and postoperative infections, which may encourage implementation of early discharge protocols in clinically stable patients.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021