Healthcare-associated infections (HCAI) are commoner amongst neurosurgical patients than amongst many other surgical patients.  As elsewhere, HCAI include surgical site, urinary, bloodstream, respiratory etc.  However, the rigid cranium, and the devastating consequences of raised intra-cranial pressure, mandate early diagnosis, aggressive management and effective prevention. Meningitis/ventriculitis, shunt infections and bone flap infections are amongst the most challenging.

Meningitis/ventriculitis is usually a device-related infection due to the presence of an external ventricular drain (EVD), and if skin flora are implicated, it can be challenging to distinguish infection from contamination or device colonisation.  The insertion of a CSF shunt can be life-saving, but infection is a major complication.  The recent UK BASICS study has shown that antibiotic-impregnated shunts reduce infection rates and are cost-effective, compared to standard and silver-impregnated shunts.  There is much confusion about what constitutes a bone flap infection and whether these represent deep infection or not.

Standard measures to reduce infections amongst all surgical patients, e.g. antibiotic prophylaxis and the early removal of all catheters and other prostheses, where possible, are as important in neurosurgery. However, the scientific evidence base for specific preventative measures in much of neurosurgery is poor, apart from a few exceptions, e.g. antibiotic-impregnated shunts and only taking CSF samples via EVDs when clinically indicated and not routinely.  Finally, once suspected, aggressive anti-infective agents are required, including intraventricular antibiotics for Gram negative meningitis/ventriculitis, to optimise outcome.