Are Prophylactic Post-Operative Antibiotics Indicated for Uncomplicated Endoscopic Skull Base Surgery?

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BACKGROUND

The endoscopic endonasal approach has become a workhorse in skull base surgery; however, the sinonasal cavity is naturally colonized by bacteria, raising concerns regarding the possibility of transmission of bacteria to the central nervous system (CNS), increasing the risk of meningitis and other infections. The risk of acquiring these infections in the post-operative setting after endoscopic skull base surgery (ESBS), and therefore the utility of routine post-operative antibiotic prophylaxis, must be weighed against considerations of antibiotic stewardship.

BEST PRACTICE

Current evidence suggests that the overall risk of meningitis and other CNS infections after ESBS is low. The risk is particularly low in uncomplicated cases where no CSF leak is encountered intra-operatively or post-operatively—for example, in uncomplicated transsphenoidal pituitary surgery. Current data have demonstrated no clear benefit to the administration of post-operative antibiotics in this group of patients. Therefore, post-operative prophylactic antibiotics are not recommended in patients undergoing uncomplicated ESBS with no CSF leak. In patients with intra-operative or post-operative CSF leaks, however, the risk of intracranial infection is considerably higher, and therefore, surgeon discretion is of paramount importance in managing this unique patient population.