Infecções em neurocirurgia

Mello, L. Renato; Boer, V. H.

doi:10.1590/S0004-282X1982000100006

Resumos

Baseado em 733 cirurgias neurológicas realizadas em um período de 50 meses, o autor expõe as providências tomadas para conter o surto infeccioso. Alterações de técnica de antissepsia e tática cirúrgica foram levadas a efeito durante os três períodos de duração do estudo. Nas duas primeiras etapas, de 17 meses cada uma, a incidência de infecção em cirurgias limpas foi de 10,3 e 6,7%. Na última etapa de 15 meses, quando se associou o uso de antibiótico tópico (oxacilina em pó), este índice caiu para 0,6%. As taxas gerais de infecção para os três períodos, somando-se as cirurgias limpas, limpas com implantes, limpas contaminadas e contaminadas foi de 7,08%, 6,8 e 3,4%, respectivamente. Uma revisão sumária dos dados de literatura referentes a antibioticoterapia profilática sistêmica e tópica antecedem os comentários sobre as bases da mudança de técnica efetuadas durante o estudo. Tricotomia próxima a operação, adoção de técnica seca para a preparação do retalho de pele e musculatura, uso exclusivo do coagulador bipolar, uso restrito de sôro epidural, e uso de oxacilina em pó antes do fechamento foram os itens principais das modificações realizadas.

The incidence of infection in neurological surgery is analysed by the author due to an almost epidemic occurrence of wound contamination by straphylococcus aureus in the year 1977. A brief review of the literature data is presented concerning the factors related to the patient's own immunity, the operative wound and the hospital environment, that may cause infection. Based on 733 operations done in a period of 50 months the author exposes the modifications installed for avoiding the infective sources. Antisseptic technic and surgical tactic were modified during the three steps of this study. In the firts two periods, each of one lasting 17 months, the infection rates for clean surgical procedures were 10,3 and 6,7% respectively. By the last 15 months, when topical oxacyllin powder was added, the infection rate droped to 0,6%. The general infection rates for clean, clean with iimplants, clean-contaminated and contaminated operations, during the three periods were 7,08, 6,8 and 3,4%. A critical review of the data concerning to systemic and topical prophylactic antibiotic therapy is followed by comments on the basis of the technical changes made in this clinical study. Shaving close to the operation, dry preparation of the scalp flap and muscle, use of only bipolar coagulation, restrict use of serum irrigation during the epidural stages of the operation an topical use of oxacillin powder before wound closure were the main technical modification introduced.

Infecções em neurocirurgia

Infections in neurosurgery

L. Renato Mello^I; V. H. Boer^II

^INeurocirurgião Chefe. Centro de Neurologia e Neurocirurgia do Hospital Santa Isabel (Blumenau, SC)

^IINeurocirurgião associado. Centro de Neurologia e Neurocirurgia do Hospital Santa Isabel (Blumenau, SC)

RESUMO

Baseado em 733 cirurgias neurológicas realizadas em um período de 50 meses, o autor expõe as providências tomadas para conter o surto infeccioso. Alterações de técnica de antissepsia e tática cirúrgica foram levadas a efeito durante os três períodos de duração do estudo. Nas duas primeiras etapas, de 17 meses cada uma, a incidência de infecção em cirurgias limpas foi de 10,3 e 6,7%. Na última etapa de 15 meses, quando se associou o uso de antibiótico tópico (oxacilina em pó), este índice caiu para 0,6%. As taxas gerais de infecção para os três períodos, somando-se as cirurgias limpas, limpas com implantes, limpas contaminadas e contaminadas foi de 7,08%, 6,8 e 3,4%, respectivamente. Uma revisão sumária dos dados de literatura referentes a antibioticoterapia profilática sistêmica e tópica antecedem os comentários sobre as bases da mudança de técnica efetuadas durante o estudo. Tricotomia próxima a operação, adoção de técnica seca para a preparação do retalho de pele e musculatura, uso exclusivo do coagulador bipolar, uso restrito de sôro epidural, e uso de oxacilina em pó antes do fechamento foram os itens principais das modificações realizadas.

SUMMARY

The incidence of infection in neurological surgery is analysed by the author due to an almost epidemic occurrence of wound contamination by straphylococcus aureus in the year 1977. A brief review of the literature data is presented concerning the factors related to the patient's own immunity, the operative wound and the hospital environment, that may cause infection. Based on 733 operations done in a period of 50 months the author exposes the modifications installed for avoiding the infective sources. Antisseptic technic and surgical tactic were modified during the three steps of this study. In the firts two periods, each of one lasting 17 months, the infection rates for clean surgical procedures were 10,3 and 6,7% respectively. By the last 15 months, when topical oxacyllin powder was added, the infection rate droped to 0,6%. The general infection rates for clean, clean with iimplants, clean-contaminated and contaminated operations, during the three periods were 7,08, 6,8 and 3,4%. A critical review of the data concerning to systemic and topical prophylactic antibiotic therapy is followed by comments on the basis of the technical changes made in this clinical study. Shaving close to the operation, dry preparation of the scalp flap and muscle, use of only bipolar coagulation, restrict use of serum irrigation during the epidural stages of the operation an topical use of oxacillin powder before wound closure were the main technical modification introduced.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Trabalho do Centro de Neurologia e Neurocirurgia do Hospital Santa Isabel (Blumenau, SC).

Centro de Neurologia e Neurocirurgia - Hospital Santa Isabel - Rua Marechal Floriano Peixoto 300 - 89100 Blumenau, SC - Brasil.

1. ALEXANDER, J. W. - Host defense mechanisms against infection. Surgical Clinics North America 52:1367, 1972.
2. AMATO NETO, V. - Antibióticos na Prática Médica. Edit. Cremed, São Paulo, 1972.
3. ANDERSEN, B.; KORNER, B. & OSTERGAARD, A. H. - Topical ampicillin against wound infection after colorectal surgery. Ann Surg. 176:129, 1972.
4. BERNARD, H. R. & COLE, W. R. - The prophylaxis of surgical infection: the effect of prophylactic antimicrobial drugs on the incidence of infection following contaminated operations. Surgery 56:151, 1974.
5. BERNARD, H. R.; COLE, W. R.; GRAVENS, D. L.; B. A. & GRAY, V. C. - Chemoprophylaxis of postoperative surgical infection. Arch. Surgery 96:476, 1968.
6. BRANDT, R. A. & FERES JR. H. - Antibióticos profiláticòs em Neurocirurgia. Arq. Neuro-psiquiatria. São Paulo, 37:42, 1979.
7. CHODAK, G. W. & PLAUT, M. E. - Use of sistemic antibiotics for prophylaxis in surgery. Arch. Surgery 112:326, 1977.
8. CRUSE, P. J. E. & FOORD, R. - A five-year prospective study of 23.649 surgical wounds. Arch. Surgery 107:206, 1973*;
9. DAVIDSON, A. I. G.; CLARK, C. & SMITH, G. - Postoperative wound infection: a computer analysis. British Surgery 58:333, 1971.
10. DINEEN, P. - An evaluation of the duration of the surgical scrub. Surgery, Gynecol, a. Obstetrics 129:1181, 1969.
11. EDLICH, R. F.; ROGERS, W.; KASPER, D.; TSUNG, M. S. & WANGENSTEEN, O. H. - Studies in the management of the contaminated wound: 1) optimal time for closure of contaminated open wounds; 2) comparison of resistence to infection of open and closed wounds during healing. American Surgery 117:323, 1969.
12. EDWARDS, L. D. - The epidemiology of 2056 remote site infections and 1966 surgical wound infections occurring in 1865 patients: a four year study of 40.923 operations at Rush Presbyterian St Luke's Hospital. Surgery 184:758, 1976.
13. FINDLAY, C. W. - Sepsis in the surgical intensive care unit. Medical Clinics North America 55:1331, 1971.
14. FULLEN, W. D.; HUNT, J. & ALTEMEIR, W. A. - Prophylactic antibiotics in wounds of the abdomen. Journal of Trauma 12:282, 1972.
15. GALLE, P. C,; HOMESLEY, H. D. & RHYNÉ, A. L. - Reassesment of the surgical scrub. Surgery, Gynecol, a. Obstetrics 147:214, 1978.
16. GARRETSON, H. D.; REID, K. H.; SHIELDS, C. B. & NOONAN, J. D. - The effete of topical aplication of antibiotics on the cerebral cortex: an experimental update. J. Neurosurgery 50:792, 1979.
17. GIBSON, R. M. - Aplication of antibiotics (poly-bactrin) in surgical practice, using the aerosol technique. Britisn Med. J. 1:1326, 1958.
18. GILMORE, O. J. A. & MARTIN, T. D. M. - Aetiology and prevention of wound infection in appendicectomy. British. Surg. 61:281, 1974.
19. HAINES, S. J. - Systemic antibiotic prophylaxis in neurological surgery. Neurosurgery 6:355, 1980.
20. HALASZ, N. A. - Wound infection and topical antibiotics: the surgeon's dilemma. Arch. Surgery 112:1240, 1977.
21. HORWITZ, N. H. & CURTIN, J. A. - Prophylactic antibiotics and wound infections following laminectomy for lumbar disc herniation: a retrospective study. J. Neurosurg. 43:727, 1975.
22. IGNELZI, R. J. & KIRSCH, W. M. - Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J. Neurosurg. 42:679, 1975.
23. IGNELZI, R. J. & VANDERARK, G. D. - Analysis of the treatment of basilar skull fractures with and without antibiotics. J. Neurosurg. 43:721, 1975.
24. JENNETT, B. & MILLER, J. D. - Infection after depressed fracture of skull: Implications for management of nonmissile injuries. J. Neurosurg. 36:333, 1972.
25. KAISER, A. B.; CALYSON, K. R.; MÜLLER JR. J. L.; ROACH, A. O.; ALLEN, T. R.;EDWARDS, W. H. & DALE, W. A. - Antibiotic prophylaxis in vascular surgery. An. Surgery 188:283, 1978.
26. KARL, R. C; MERTZ, J. J.; VEITH, F. J. & DINEEN, P. - Prophylactic antimicrobial drugs in surgery. New England Medicine 275:305, 1966.
27. KRISS, E. C; TAREN, J. A. & KAHN, E. A. - Primary repair of compund skull fractures by replacement of bone fragments. J. Neurosurg. 30:698, 1969.
28. LAWS, E. R. & KERN, E. B. - Complication of trans-sphenoidal surgery. Clin. Neurosurg. 23:401, 1975.
29. LORBER, J.; KALHAN, S. & MAHGREFTE, B. - Treatment of ventriculitis with gentamicin and cloxacilin in infants born with spina bifida. Arch. Disease in Childhood 45:178, 1970.
30. LOUGHLIN, J. M. O. - Infections in the immunosuppressed patient. Medical Clinics of North America 59:495, 1975.
31. MACGEE, E. E.; CAUTHEN, J. C. & BRACKETT, C. E. - Meningitis following acute traumatic cerebrospinal fluid fistula. J. Neurosurg. 33:312, 1970.
32. MALIS, L. I. - Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 5:339, 1979.
33. MCCULLOUGH, D. C; KANE, J. G.; PRESPER, J. H. & WELLS, M. - Antibiotic prophylaxis in ventricular shunt surgery: reduction of operative infecrates with methicilin. Child's Brain, 7:182, 1980.
34. MCCULLOUGH, D. C; KANE, J. G.; PRESPER, J. H. & WELLS, H. - Antibiotic prophylaxis in ventricular shunt surgery: antibiotic concentrations in cerebrospinal fluid. Child's Brain, 7:190, 1980.
35. MEAKINS, J. L. - Pathophysiologic determinants and prediction of sepsis. Surgical Clinics North America 56:847, 1976.
36. MERVINE, T. B.; GORACCI, A. F. & .NICOLL, G. S. - The handling of contaminated abdominal wounds. Surgical Clinics of Nort America 53:611, 1973.
37. NADELL, J. & KLINE, D. G. - Primary reconstruction of depressed frontal skull fractures including those involving the sinus, orbit and cribriform plate. J. Neurosurg. 41:200, 1974.
38. National Academy of Sciences, National Research Coucil - Postoperative wound infectiions: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann. Surg. 160:23, 1964.
39. OMMAYA, A. K. - Spinal fluid fistulas Clin. Neurosurg. 23:363, 1975.
40. PASKIN, D. L. & LEMER, H. J. - A prospective study of wound infections. The American Surgeon 35:627, 1969.
41. PERTUISET, B. - Supratentorial craniotomy. In Advances and Technical Standards in Neurosurgery. Springer Verlag, New York, 143-171, 1974.
42. POLK, H. & MAYOR-LOPEZ, J. F. - Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery 66:97, 1969.
43. POLK JR., H. C. - Diminished surgical infection by systemic antibiotic administration in potentially contaminated operations. Surgery 75:312, 1974.
44. POLK JR., H. C; FRY, D. & FLINT JR., L. M. - Dissemination and cause of infection. Surgical Clinics of North America 56:817, 1976.
45. QUADERY, L. A.; MEDLERY, A. V. & MILES, J. - Factors affecting the incidence of wound infection in neurosurgery. Acta Neurochir. (Wien) 39:133, 1977.
46. QUESNEL, L. B. - The efficiency of surgical masks of variyng design and composition. British Surgery 62:936, 1975.
47. QUINTILIANI, R. & LENTNEK, A. - Polymixin B in the treatment of klebsiella pneumoniae meningoventriculitis. Amer. J. Dis. Child. 121:239, 1971.
48. RAAHAVE, D. - Effect of plastic skin and wound drapes on the density of bacteria in operation wounds. British Surgery. 64:421, 1976.
49. SALMON, J. H. - Adult hydrocephalus: evaluation of shunt therapy in 80 patients. J. Neurosurg. 37:423, 1972.
50. SALMON, J. H. - Ventriculitis complicating meningitis. Amer. J. Dis. Child. 124:35, 1972.
51. SAVITZ, M. H.; MALIS, L. I. & METERS, B. R. - Prophylactic antibiotics in neurosurgery. Surg. Neurol. 2:95, 1974.
52. SAVITZ, M. H. & MALIS, L. I. - Prophylactic clindamycin for neurosurgical patients. New York. State J. Med. 76:64, 1976.
53. SEROPIAN, R. & REYNOLDS, M. - Wound infections after postoperative depilatory versus razor preparation. American Surgery. 121:251, 1971.
54. SHURTLEFF, D. B.; CHRISTIE, D. & FOLTZ, E. L. - Ventriculoamiculostomy associated infection: 12 year study. J. Neurosurg. 35:686, 3971.
55. SMITH, R. W. & ALKSNE, J. F. - Infections complicating the use of external ventriculostomy. J. Neurosurg. 44:567, 1976.
56. STONE, H. H.; HOOPER, C. A.; KOLB, L. D.; GEHEBER, C. & DAWKINS, E. J. - Antibiotic prophylaxis in gastric biliary and colonic surgery. Ann. Surgery. 184:443, 1976.
57. TAYLOR, F. W. - An experimental evaluation of operative wound irrigation. Surg. Gynecol. Obstet. 113:465, 1961.
58. TODD, J. C. - Wound infection: etiology, prevention and management. Surgical Clinics North America 48:787, 1968.
59. VENES, J. L. - Control of shunt infection: report of 150 consecutive cases. J. Neurosurg. 45:311, 1976.
60. WATERMANN, N. G.; HOWELL, R. S. & BABICH, M. - The effect of a prophylactic topical antibiotic (Cephalothin) on the incidente of wound infection. Arch. Surg. 97:365, 1968.
61. WEISS, M. H.; KURZE, T. & NULSEN, F. - Antibiotic neurotoxicity: laboratory and clinical study. J. Neurosurgery 41:486, 1974.
62. WYLER, A. R. & KELLY, W. A. - Use of antibiotic with external ventriculostomies. J. Neurosurg. 37:185, 1972.

Datas de Publicação

Publicação nesta coleção
16 Ago 2012
Data do Fascículo
Mar 1982

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ALEXANDER, J. W. - Host defense mechanisms against infection. Surgical Clinics North America 52:1367, 1972.

[2] 2. AMATO NETO, V. - Antibióticos na Prática Médica. Edit. Cremed, São Paulo, 1972.

[3] 3. ANDERSEN, B.; KORNER, B. & OSTERGAARD, A. H. - Topical ampicillin against wound infection after colorectal surgery. Ann Surg. 176:129, 1972.

[4] 4. BERNARD, H. R. & COLE, W. R. - The prophylaxis of surgical infection: the effect of prophylactic antimicrobial drugs on the incidence of infection following contaminated operations. Surgery 56:151, 1974.

[5] 5. BERNARD, H. R.; COLE, W. R.; GRAVENS, D. L.; B. A. & GRAY, V. C. - Chemoprophylaxis of postoperative surgical infection. Arch. Surgery 96:476, 1968.

[6] 6. BRANDT, R. A. & FERES JR. H. - Antibióticos profiláticòs em Neurocirurgia. Arq. Neuro-psiquiatria. São Paulo, 37:42, 1979.

[7] 7. CHODAK, G. W. & PLAUT, M. E. - Use of sistemic antibiotics for prophylaxis in surgery. Arch. Surgery 112:326, 1977.

[8] 8. CRUSE, P. J. E. & FOORD, R. - A five-year prospective study of 23.649 surgical wounds. Arch. Surgery 107:206, 1973*;

[9] 9. DAVIDSON, A. I. G.; CLARK, C. & SMITH, G. - Postoperative wound infection: a computer analysis. British Surgery 58:333, 1971.

[10] 10. DINEEN, P. - An evaluation of the duration of the surgical scrub. Surgery, Gynecol, a. Obstetrics 129:1181, 1969.

[11] 11. EDLICH, R. F.; ROGERS, W.; KASPER, D.; TSUNG, M. S. & WANGENSTEEN, O. H. - Studies in the management of the contaminated wound: 1) optimal time for closure of contaminated open wounds; 2) comparison of resistence to infection of open and closed wounds during healing. American Surgery 117:323, 1969.

[12] 12. EDWARDS, L. D. - The epidemiology of 2056 remote site infections and 1966 surgical wound infections occurring in 1865 patients: a four year study of 40.923 operations at Rush Presbyterian St Luke's Hospital. Surgery 184:758, 1976.

[13] 13. FINDLAY, C. W. - Sepsis in the surgical intensive care unit. Medical Clinics North America 55:1331, 1971.

[14] 14. FULLEN, W. D.; HUNT, J. & ALTEMEIR, W. A. - Prophylactic antibiotics in wounds of the abdomen. Journal of Trauma 12:282, 1972.

[15] 15. GALLE, P. C,; HOMESLEY, H. D. & RHYNÉ, A. L. - Reassesment of the surgical scrub. Surgery, Gynecol, a. Obstetrics 147:214, 1978.

[16] 16. GARRETSON, H. D.; REID, K. H.; SHIELDS, C. B. & NOONAN, J. D. - The effete of topical aplication of antibiotics on the cerebral cortex: an experimental update. J. Neurosurgery 50:792, 1979.

[17] 17. GIBSON, R. M. - Aplication of antibiotics (poly-bactrin) in surgical practice, using the aerosol technique. Britisn Med. J. 1:1326, 1958.

[18] 18. GILMORE, O. J. A. & MARTIN, T. D. M. - Aetiology and prevention of wound infection in appendicectomy. British. Surg. 61:281, 1974.

[19] 19. HAINES, S. J. - Systemic antibiotic prophylaxis in neurological surgery. Neurosurgery 6:355, 1980.

[20] 20. HALASZ, N. A. - Wound infection and topical antibiotics: the surgeon's dilemma. Arch. Surgery 112:1240, 1977.

[21] 21. HORWITZ, N. H. & CURTIN, J. A. - Prophylactic antibiotics and wound infections following laminectomy for lumbar disc herniation: a retrospective study. J. Neurosurg. 43:727, 1975.

[22] 22. IGNELZI, R. J. & KIRSCH, W. M. - Follow-up analysis of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus. J. Neurosurg. 42:679, 1975.

[23] 23. IGNELZI, R. J. & VANDERARK, G. D. - Analysis of the treatment of basilar skull fractures with and without antibiotics. J. Neurosurg. 43:721, 1975.

[24] 24. JENNETT, B. & MILLER, J. D. - Infection after depressed fracture of skull: Implications for management of nonmissile injuries. J. Neurosurg. 36:333, 1972.

[25] 25. KAISER, A. B.; CALYSON, K. R.; MÜLLER JR. J. L.; ROACH, A. O.; ALLEN, T. R.;EDWARDS, W. H. & DALE, W. A. - Antibiotic prophylaxis in vascular surgery. An. Surgery 188:283, 1978.

[26] 26. KARL, R. C; MERTZ, J. J.; VEITH, F. J. & DINEEN, P. - Prophylactic antimicrobial drugs in surgery. New England Medicine 275:305, 1966.

[27] 27. KRISS, E. C; TAREN, J. A. & KAHN, E. A. - Primary repair of compund skull fractures by replacement of bone fragments. J. Neurosurg. 30:698, 1969.

[28] 28. LAWS, E. R. & KERN, E. B. - Complication of trans-sphenoidal surgery. Clin. Neurosurg. 23:401, 1975.

[29] 29. LORBER, J.; KALHAN, S. & MAHGREFTE, B. - Treatment of ventriculitis with gentamicin and cloxacilin in infants born with spina bifida. Arch. Disease in Childhood 45:178, 1970.

[30] 30. LOUGHLIN, J. M. O. - Infections in the immunosuppressed patient. Medical Clinics of North America 59:495, 1975.

[31] 31. MACGEE, E. E.; CAUTHEN, J. C. & BRACKETT, C. E. - Meningitis following acute traumatic cerebrospinal fluid fistula. J. Neurosurg. 33:312, 1970.

[32] 32. MALIS, L. I. - Prevention of neurosurgical infection by intraoperative antibiotics. Neurosurgery 5:339, 1979.

[33] 33. MCCULLOUGH, D. C; KANE, J. G.; PRESPER, J. H. & WELLS, M. - Antibiotic prophylaxis in ventricular shunt surgery: reduction of operative infecrates with methicilin. Child's Brain, 7:182, 1980.

[34] 34. MCCULLOUGH, D. C; KANE, J. G.; PRESPER, J. H. & WELLS, H. - Antibiotic prophylaxis in ventricular shunt surgery: antibiotic concentrations in cerebrospinal fluid. Child's Brain, 7:190, 1980.

[35] 35. MEAKINS, J. L. - Pathophysiologic determinants and prediction of sepsis. Surgical Clinics North America 56:847, 1976.

[36] 36. MERVINE, T. B.; GORACCI, A. F. & .NICOLL, G. S. - The handling of contaminated abdominal wounds. Surgical Clinics of Nort America 53:611, 1973.

[37] 37. NADELL, J. & KLINE, D. G. - Primary reconstruction of depressed frontal skull fractures including those involving the sinus, orbit and cribriform plate. J. Neurosurg. 41:200, 1974.

[38] 38. National Academy of Sciences, National Research Coucil - Postoperative wound infectiions: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann. Surg. 160:23, 1964.

[39] 39. OMMAYA, A. K. - Spinal fluid fistulas Clin. Neurosurg. 23:363, 1975.

[40] 40. PASKIN, D. L. & LEMER, H. J. - A prospective study of wound infections. The American Surgeon 35:627, 1969.

[41] 41. PERTUISET, B. - Supratentorial craniotomy. In Advances and Technical Standards in Neurosurgery. Springer Verlag, New York, 143-171, 1974.

[42] 42. POLK, H. & MAYOR-LOPEZ, J. F. - Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery 66:97, 1969.

[43] 43. POLK JR., H. C. - Diminished surgical infection by systemic antibiotic administration in potentially contaminated operations. Surgery 75:312, 1974.

[44] 44. POLK JR., H. C; FRY, D. & FLINT JR., L. M. - Dissemination and cause of infection. Surgical Clinics of North America 56:817, 1976.

[45] 45. QUADERY, L. A.; MEDLERY, A. V. & MILES, J. - Factors affecting the incidence of wound infection in neurosurgery. Acta Neurochir. (Wien) 39:133, 1977.

[46] 46. QUESNEL, L. B. - The efficiency of surgical masks of variyng design and composition. British Surgery 62:936, 1975.

[47] 47. QUINTILIANI, R. & LENTNEK, A. - Polymixin B in the treatment of klebsiella pneumoniae meningoventriculitis. Amer. J. Dis. Child. 121:239, 1971.

[48] 48. RAAHAVE, D. - Effect of plastic skin and wound drapes on the density of bacteria in operation wounds. British Surgery. 64:421, 1976.

[49] 49. SALMON, J. H. - Adult hydrocephalus: evaluation of shunt therapy in 80 patients. J. Neurosurg. 37:423, 1972.

[50] 50. SALMON, J. H. - Ventriculitis complicating meningitis. Amer. J. Dis. Child. 124:35, 1972.

[51] 51. SAVITZ, M. H.; MALIS, L. I. & METERS, B. R. - Prophylactic antibiotics in neurosurgery. Surg. Neurol. 2:95, 1974.

[52] 52. SAVITZ, M. H. & MALIS, L. I. - Prophylactic clindamycin for neurosurgical patients. New York. State J. Med. 76:64, 1976.

[53] 53. SEROPIAN, R. & REYNOLDS, M. - Wound infections after postoperative depilatory versus razor preparation. American Surgery. 121:251, 1971.

[54] 54. SHURTLEFF, D. B.; CHRISTIE, D. & FOLTZ, E. L. - Ventriculoamiculostomy associated infection: 12 year study. J. Neurosurg. 35:686, 3971.

[55] 55. SMITH, R. W. & ALKSNE, J. F. - Infections complicating the use of external ventriculostomy. J. Neurosurg. 44:567, 1976.

[56] 56. STONE, H. H.; HOOPER, C. A.; KOLB, L. D.; GEHEBER, C. & DAWKINS, E. J. - Antibiotic prophylaxis in gastric biliary and colonic surgery. Ann. Surgery. 184:443, 1976.

[57] 57. TAYLOR, F. W. - An experimental evaluation of operative wound irrigation. Surg. Gynecol. Obstet. 113:465, 1961.

[58] 58. TODD, J. C. - Wound infection: etiology, prevention and management. Surgical Clinics North America 48:787, 1968.

[59] 59. VENES, J. L. - Control of shunt infection: report of 150 consecutive cases. J. Neurosurg. 45:311, 1976.

[60] 60. WATERMANN, N. G.; HOWELL, R. S. & BABICH, M. - The effect of a prophylactic topical antibiotic (Cephalothin) on the incidente of wound infection. Arch. Surg. 97:365, 1968.

[61] 61. WEISS, M. H.; KURZE, T. & NULSEN, F. - Antibiotic neurotoxicity: laboratory and clinical study. J. Neurosurgery 41:486, 1974.

[62] 62. WYLER, A. R. & KELLY, W. A. - Use of antibiotic with external ventriculostomies. J. Neurosurg. 37:185, 1972.