Surgical site infections in neurosurgical patients following cranial surgery: An integrative review

Patients who present with head trauma or disorders affecting the brain may require surgical intervention for treatment. A surgical procedure known as cranial surgery is often performed to enable clinical management for cerebral bleeds, removal of brain tumours, evacuation of extradural or subdural haematomas, treatment for hydrocephalus, or decompression of cranial nerves (Abecassis & Kim, 2017). A major complication that occurs following cranial surgery is widely reported to be in the form of surgical site infections (SSIs) (Abu Hamdeh et al., 2014; Kose et al., 2016, Kraft et al., 2022). SSIs are infections that develop within either thirty days following surgery or a year if an implant remains indwelling post operatively (Bhatti & Leach, 2013).

SSIs are common nosocomial infections among neurosurgical patients, and they account for approximately 5% of all nosocomial outbreaks (Abu Hamdeh et al., 2014; Bekelis et al., 2016). The most widely reported pathogens that cause SSIs include Staphylococcus aureus, Enterococci, Pseudomonas aeruginosa, Escherichia coli, Streptococci, Enterobacter species, Proteus species, and Serratia species (Garner & Anderson, 2016; Seidelman & Anderson, 2021).

Within the hospital setting, SSIs post cranial surgery are associated with high morbidity among patients and increased hospital resource utilisation (Davies et al., 2016; Mann et al., 2021; Riordan et al., 2016, Patel et al., 2019). SSIs result in increased length of hospital stay, prolonged use of antibiotics, and inpatient mortality (Fiani et al., 2020). Patients who develop SSIs after discharge from hospital may require readmission for further corrective treatment, heightening family strain and caregiver burden. (Royle et al., 2023; Sebastian, 2012).

A review of published statistical data revealed that the overall estimated SSI rate in Australian public hospitals equated to 66 cases per 100,000 population and 16,541 cases were recorded annually at a treatment cost of A$323.50 million (Royle et al., 2023). The burden of SSIs for both public and private hospitals was estimated to be A$6.8 billion (Royle et al., 2023). The lack of a centralised or national surveillance system to track SSIs in both public and private healthcare settings in Australia encumbers the computation of the true burden of SSIs. In the United States of America (USA), approximately 300,000 SSIs occur each year and between 1% to 5% of inpatients develop SSIs post operatively (Seidelman & Anderson, 2021). The estimated annual healthcare expenditure associated with SSIs ranges from US$3.5 to US$10 billion depending on the surgical site and wound classification (Khan et al., 2020; Seidelman & Anderson, 2021). In Europe, SSIs constitute up to 19.6% of all Hospital Acquired Infections (HAIs) (Badia et al., 2017). Across a sample of 12 European nations, an estimated incidence rate of SSIs ranging from 0.6% to 9.5% was established from as cohort of 1.2 million surgical cases (European Centre for Disease Prevention and Control [ECDC], 2023). The global incidence for SSIs varied from 0.5% to 11% among patients who underwent cranial surgery (Ehrlich et al., 2016; Fiani et al., 2020). Low and middle income countries have the highest incidence rates for SSIs ranging from 1% to 24% (Seidelman & Anderson, 2021).The general signs and symptoms for SSIs include pain, swelling, redness, purulent discharge, wound dehiscence, foul odour, local erythema and delayed healing (Harrington, 2014; Hweidi et al., 2018; Schuderer et al., 2022; Seidelman & Anderson, 2021).

The clinical manifestation of post cranial SSIs pauses a major global public health care problem (Abu Hamdeh et al., 2014). However, to date, a broad review of the literature pertaining to neurosurgical patients following cranial surgery has not been explored. Hence to address this gap in literature, this integrative review was warranted. The review outcomes will generate information that can inform and guide neurosurgical nurses in the clinical nursing management of post cranial surgical patients.

The four main themes that emerged included: (1) preoperative patient preparatory practices and SSIs; (2) risk factors for developing SSIs post cranial surgery; (3) patient-reported outcomes and healthcare implications, and (4) strategies for preventing SSIs within healthcare settings. These themes are presented below in detail:

This integrative review synthesised the literature pertaining to surgical site infections in neurosurgical patients following cranial surgery. The four main themes that emerged pertained to preoperative patient preparatory practices and SSIs; risk factors for developing SSIs post cranial surgery, patient-reported outcomes and healthcare implications; and strategies for preventing SSIs within hospital settings. Shaving of patients’ hair before cranial surgery was a major practice in many neurosurgical hospital settings but critical evidence suggested that the practice can alter normal skin-flora and consequently heighten the risk for developing SSIs (Bhatti & Leach, 2013). However, this finding was derived from a prospective study that recruited participants at a single research site (Bhatti & Leach, 2013) and a larger study may be warranted to consolidate clinical evidence. Additional findings indicated that hair shaving can also alter the skin bacterial composition through exposing the scalp to microscopic trauma and result in patients being more prone to SSIs (Kerk et al., 2018).

Comparable studies reported that hair removal had no benefit for patients in terms of reducing SSIs (Çelik, 2004; Shi, Yao & Yu, 2017).Thus, there appears to be an imperative prerequisite for neurosurgical nurses to exercise clinical judgement when considering whether to shave or not to shave patients’ hair when preparing for cranial surgery as the consequences from the practice could outweigh the benefits. There is a gap between neurosurgical clinical nursing practice and theoretical knowledge around shaving patients’ hair prior to cranial surgery and this is an area that can benefit from further empirical research.

Another finding from the review was that cranial surgical procedures that took longer periods to complete increased the risk for developing SSIs (Bekelis et al., 2016; Patel et al., 2019). Of specific note was that cranial surgical procedures that lasted longer than four hours enhanced the risk for post-operative SSIs (Jeong & Yee, 2018; Patel et al., 2019). Similarly, longer cranial surgeries provided an avenue for infective microorganisms from external sources such as surgical instruments and healthcare personnel to colonise the surgical site (Golebiowski et al., 2015). In consideration of these findings, shorter periods for cranial surgeries were advised as they were more likely to yield positive outcomes for patients post operatively (Abu Hamdeh et al., 2004). Unforeseeable organisational factors such as the lack of adequate clinical and support resources can also influence the duration of cranial surgery (Storey, 2013). However, these findings highlight the potential downside of prolonged cranial procedures which nurses can monitor and manage when fulfilling the role of being patient-advocates.

The risk factors for developing SSIs comprised of patient-specific and external factors. The patient-specific factors which heightened the risk for acquiring SSIs included having comorbidities or other diseases such as diabetes, and malignant tumours (Cassir et al., 2015). Having diabetes increased the risk for developing SSIs by up to 60% (Coleman et al., 2010). A major uncontrollable external factor was described as having a redo or repeat cranial surgery in the absence of any other non-invasive interventional alternatives (Cassir et al., 2015; Abu Hamdeh et al., 2004; Wathen et al., 2016). The modifiable external risk factors included shaving of hair prior to cranial surgery, using staples for wound closure; and having indwelling devices such as wound drains (Jiménez-Martínez et al., 2021; Abu Hamdeh et al., 2004; Yao & Liu, 2019). Considering that the external risk factors are modifiable, neurosurgical nurses should aim to address them in order to enhance positive outcomes for patients post cranial surgery. For instance, ensuring timely administration of antimicrobial prophylaxis was a key modifiable risk factor that was associated with a decrease in SSIs (Harrington, 2014). However, neurosurgical nurses should exercise caution with antimicrobial administration as excessive usage can lead to antimicrobial resistance (Velez & Sloand, 2016). There are a number of interventions that can be initiated by neurosurgical nurses to prevent the spread of SSIs for inpatients post cranial surgery. For instance, the implementation of well-coordinated SSIs surveillance practices such as performing daily wound assessments, and enacting SSIs prevention control measures such as keeping blood glucose levels under control for patients with diabetes (Cassir et al., 2015; Erman et al., 2007; Harrington, 2014; Honeybul & Ho, 2016; Hweidi et al., 2018; Moorthy, Sarkar, & Rajshekhar, 2013; Odom-Forren, 2006; Shi et al., 2017). Other strategies that can assist in the prevention of SSIs include practicing regular hand hygiene and applying aseptic precautions when attending to surgical site care (Smith & Dahlen, 2013). In addition, providing patient education regarding surgical wound care, performing accurate wound assessments using a structured wound assessment tool and maintaining proper wound care documentation can assist in curbing SSIs through supporting vigilance and informing multidisciplinary team wound management (Chen et al., 2013; Gillespie et al., 2014; Murakami et al., 2013). Preventing cranial SSIs in hospital settings necessitates working within an initiative-taking multidisciplinary team environment with the aim of enhancing positive post-operative outcomes for patients (Lailama et al., 2021).

The primary limitation for this integrative review is that only peer reviewed studies that were published in English were considered and there is a possibility that some pertinent studies may have been missed. The review was dependent on the search terms applied along with the databases accessed and therefore it is possible that studies indexed elsewhere were omitted. Larger reviews should aim to incorporate studies from other languages and diverse databases in order to broaden the understanding of SSIs post cranial surgery.

This integrative review synthesised the literature pertaining to surgical site infections in neurosurgical patients following cranial surgery. The key findings indicate that risks for developing SSIs in neurosurgical patients remains a major health problem for patients, families and healthcare providers. Preoperative patient preparatory practices such as shaving patient hair can contribute to heightening the risk for contracting SSIs. The risks for developing SSIs were categorised as modifiable and non-modifiable. Patient-reported outcomes reflected on the burden that contracting SSIs bears on patients and their families. Healthcare providers and neurosurgical nurses in particular play a major role in preventing SSIs among individuals who present for cranial surgery in hospital settings. Future research should expand the findings of this review and explore how neurosurgical nurses can empower patients to become self-reliant in managing modifiable risk factors in order to prevent SSIs post cranial surgery.