Introduction: Vagal nerve stimulators (VNS) are a mainstay in the treatment of generalized medically refractory epilepsy. They are not without complications including infection rates of 3-8%. Current guidelines for antibiotic prophylaxis of surgical site infections are a single dose of antibiotics 30 minutes prior to incision, without evidence supporting continued administration. In line with that, we administer a single dose of vancomycin prior to incision and discharge patients following anesthesia recovery. We propose that our infection rate is on par with historical policies admitting patients postoperatively for 24 hours of antibiotics.
Methods: A retrospective chart review was performed on all children who underwent VNS implantation at CHLA from 1998-2013, receiving only a single dose of antibiotics pre-operatively. We analyzed patient, epilepsy and surgery related factors. We compared our infection rate to published data.
Results: Over the past 15 years, 143 children with medically refractory epilepsy underwent placement of a VNS with single dose antibiotic prophylaxis. There were only 3 infections (all Staph aureus) following implantation for a rate of 2%. Our patient population underwent 54 VNS revisions/battery changes under a single dose of vancomycin, with 3 Staph aureus infections (revision infection rate = 5.5%, lead revisions n=2, battery n=1). Infections were unrelated to operative duration, number or type of surgeons scrubbed, timing or dose of vancomyin, patient age, diagnosis or weight.
Conclusions: A single dose of vancomycin prior to VNS surgery is effective prophylaxis of surgical site infections with a comparable infection rate to published statistics which include an overnight admission and 24 hour antibiotic administration. Overnight hospital stays create a burden on families and cause undo stress to the patient. Implanting a VNS as an outpatient surgery can result in significant cost savings to the patients, their families and the healthcare system.
Patient Care: Level 1 evidence supports single dose antibiotic administration prior to surgery, without prolonged administration. Despite that, many surgeons still administer prolonged courses. By developing a treatment plan that supports that evidence, we are demonstrating that this holds true for the implantation of a vagal nerve stimulator. From a qualitative standpoint, this reduces the burden on the family and healthcare system. We are currently calculating the cost savings associated with this protocol.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the guidelines for surgical site prophylaxis 2) Discuss whether a common neurosurgical practice of 24 hrs of antibiotic prophylaxis is necessary 3) Appreciate the potential economic impact of reducing length of stay and hospital cost