The Use And Impact Of Antimicrobial Prophylaxis In Neurosurgery At Kenyatta National Hospital

293 Pages·2016·3.01 MB·English

UNIVERSITY OF NAIROBI
SCHOOL OF PHARMACY

THE USE AND IMPACT OF ANTIMICROBIAL PROPHYLAXIS IN
NEUROSURGERY AT KENYATTA NATIONAL HOSPITAL, AND THE ECONOMIC
IMPACT OF TREATMENT OF NEUROSURGICAL SITE INFECTIONS.

SYLVIA ATISA OPANGA B. Pharm, M. Pharm (Clinical Pharmacy)
U80/95607/2014

A thesis submitted in partial fulfilment of the requirements for the Degree of Doctor of
Philosophy in Clinical Pharmacy of the University of Nairobi.

NOVEMBER, 2016
i
Declaration
This thesis is my original work and has not been submitted to any other university for a degree
award.
Signed: _____________________________ _______________________
Sylvia A. Opanga Date
U80/95607/2014
Department of Pharmaceutics and Pharmacy Practice,
School of Pharmacy, University of Nairobi.
This thesis has been submitted with our approval as university supervisors.

Signed: __________________________________ ____________________
Prof Kimani A.M Kuria Date
Department of Pharmaceutics and Pharmacy Practice,
School of Pharmacy, University of Nairobi.

Signed: __________________________________ ____________________
Prof Nimrod J. Mwang’ombe Date
Division of Neurosurgery,
School of Medicine, University of Nairobi.

Signed: __________________________________ ____________________
Dr Faith A. Okalebo Date
Department of Pharmacology and Pharmacognosy,
School of Pharmacy, University of Nairobi.
i
Dedication
To the Almighty God who enabled me to start, perfect and complete this good work (Philippians
1:6).
To my father, The Late Walter Raleigh Opanga, for being the best dad, believing in me and
always encouraging me to achieve the highest degree of excellence while he was alive.

ii
Acknowledgements
I would like to thank The Almighty God who has been with me every step of the way, guiding
me and equipping me with the wisdom I needed to start and complete this thesis. I acknowledge
my supervisors for guiding me from the start of the thesis to the end. I acknowledge the Gandhi
Smarak Nidhi Fund for providing me a partial scholarship that enabled me to carry out the
research. Finally, I would like to thank my best friend Gabriella Ligami for constantly
encouraging me and praying with me when I was discouraged and things were not moving
forward.

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TABLE OF CONTENT

Declaration.............................................................................................................................................. i
Dedication ............................................................................................................................................. ii
Acknowledgements ............................................................................................................................. iii
List of Tables ...................................................................................................................................... xiv
List of Figures ...................................................................................................................................... xv
List of Acronyms .............................................................................................................................. xvii
Abstract ........................................................................................................................................... xxii
CHAPTER 1: INTRODUCTION ........................................................................................................ 1
1.1 Neurosurgery ................................................................................................................................. 1
1.2 Infections in Neurosurgery ............................................................................................................ 1
1.3 Surgical Site Infections ................................................................................................................. 2
1.4. Study Problem ............................................................................................................................ 3
1.5 Research Questions ....................................................................................................................... 4
1.6 Study Objectives ........................................................................................................................... 5
1.7 Conceptual Framework for the Study: .......................................................................................... 6
1.8 Justification of the Study ............................................................................................................... 7
1.9. Summary of the Methodological Approach in The study ............................................................ 9
CHAPTER 2: LITERATURE REVIEW ......................................................................................... 10
2.1. NEUROSURGICAL PROCEDURES AND RISK OF CONTAMINATION .................... 10
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2.1.1. Classifications of Surgical Wounds in Neurosurgery ......................................................... 10
2.2. PATHOLOGY AND CLINICAL FEATURES OF SURGICAL SITE INFECTIONS .... 11
2.2.1. Clinical Examination of Surgical Site Infections ................................................................ 11
2.2.2. Classification of Surgical Site Infections ............................................................................ 12
2.3. RISK FACTORS FOR SURGICAL SITE INFECTIONS .................................................. 15
2.3.1. Patient Risk Factors for Development of SSIs .................................................................... 15
2.3.2 Procedure Related Risk Factors for SSIs.............................................................................. 18
2.4. RISK CATEGORIZATION OF PATIENTS UNDERGOING SURGICAL
PROCEDURES ........................................................................................................................ 20
2.5. PREVENTION OF SURGICAL SITE INFECTIONS ........................................................ 22
2.5.1 Antimicrobial Prophylaxis.................................................................................................... 22
2.5.2 Surgical Procedures that Prevent SSIs ................................................................................. 26
2.6: IMPLEMENTATION OF INFECTION CONTROL PROTOCOLS ................................ 28
2.7 THE GRADE SYSTEM FOR EVALUATING QUALITY OF EVIDENCE ...................... 30
2.8. REFERENCES: ........................................................................................................................ 33
CHAPTER 3: SYSTEMATIC REVIEW, META-ANALYSIS AND GRADING OF
EVIDENCE ON THE EFFECTIVENESS OF ANTIMICROBIAL
PROPHYLAXIS FOR NEUROSURGICAL SITE INFECTIONS ............................... 48
3.1. Introduction ................................................................................................................................ 48
3.2. Objective .................................................................................................................................... 50
3.3. Methods: ..................................................................................................................................... 50
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3.3.1. Selection of Studies: PICO and Search Strategy: ................................................................ 50
3.3.2. Inclusion and Exclusion Criteria for the Studies: ................................................................ 52
3.3.3. Search for Systematic Reviews and Randomised Controlled Trials: .................................. 53
3.3.4. Title Screening: ................................................................................................................... 53
3.3.5. Abstract Screening: ............................................................................................................. 53
3.3.6. Full Text Analysis of Selected Studies:............................................................................... 54
3.3.7. Data Abstraction: ................................................................................................................. 57
3.3.8. Meta- Analysis: ................................................................................................................... 59
3.4. RESULTS: ................................................................................................................................ 61
3.4.1. Antibiotics versus Placebo/ No Antibiotics:........................................................................ 61
3.4.2. Meta-Analysis 2: Antimicrobial Impregnated Shunt Catheters versus Standard Shunts: ... 75
3.4.3. Studies Excluded from Meta-Analysis and Grade Evaluation: ........................................... 84
3.5. DISCUSSION: .......................................................................................................................... 84
3.6. CONCLUSION AND RECOMMENDATIONS ................................................................... 89
3.7. REFERENCES ......................................................................................................................... 90
CHAPTER 4: A SURVEY OF THE PREVALENCE AND PATIENT RISK FACTORS
FOR THE DEVELOPMENT OF SURGICAL SITE INFECTION AND
INFECTION CONTROL PROCEDURES IN THE NEUROSURGICAL WARD
OF KENYATTA NATIONAL HOSPITAL..................................................................... 96
4.1 Introduction ................................................................................................................................. 96
4.1.1 Study Problem ...................................................................................................................... 98
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4.1.2 Research Questions .............................................................................................................. 99
4.1.3 Objectives ............................................................................................................................. 99
4.2. Methods .................................................................................................................................... 100
4.2.1 Study Design and Population ............................................................................................. 100
4.2.2 Inclusion and Exclusion Criteria ........................................................................................ 100
4.2.3 Sample Size Calculation ..................................................................................................... 101
4.2.4. Sampling and Study Participant Recruitment.................................................................... 101
4.2.5 Data Collection ................................................................................................................... 102
4.2.6 Case Definition ................................................................................................................... 102
4.2.7 Variables ............................................................................................................................. 103
4.2.8 Data Analysis...................................................................................................................... 104
4.2.9 Data Management ............................................................................................................... 105
4.2.10 Quality Assurance ............................................................................................................ 106
4.2.11 Ethical Considerations ...................................................................................................... 106
4.3. Results ...................................................................................................................................... 107
4.3.1. Baseline Characteristics and Demographics of Patients ................................................... 107
4.3.2. Medical and Surgical History of the Patients .................................................................... 108
4.3.3. Prevalence of Patient Related Risk Factors ....................................................................... 109
4.3.4. Perioperative Infection Control Procedures: ..................................................................... 110
4.3.5. Surgical Procedures and Duration of Surgery ................................................................... 110
4.3.6 Prevalence and Types of Surgical Site Infections .............................................................. 111
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4.3.7. Bi-variable Analysis- Comparison Traits of Those Who Developed Infections and
Those Who Did Not. ...................................................................................................... 112
4.4. Discussion ................................................................................................................................ 117
4.5. Conclusion ................................................................................................................................ 121
4.6. Recommendations .................................................................................................................... 121
4.7. References ................................................................................................................................ 122
CHAPTER 5: IMPACT OF ANTIMICROBIAL PROPHYLAXIS ON INCIDENCE OF
SURGICAL SITE INFECTIONS ................................................................................... 125
5.1. INTRODUCTION .................................................................................................................. 125
5.1.1 Study Problem .................................................................................................................... 126
5.1.2 Research Questions ............................................................................................................ 126
5.1.3. Objectives .......................................................................................................................... 127
5.1.4. Hypotheses ........................................................................................................................ 127
5.2. METHODS ............................................................................................................................. 128
5.2.1. Study Design and Population ............................................................................................ 128
5.2.2. Inclusion and Exclusion Criteria ....................................................................................... 128
5.2.3. Sampling and Participant Recruitment Strategies ............................................................. 128
5.2.4 Sampling ............................................................................................................................. 129
5.2. 5. Data Collection ................................................................................................................. 129
5.2.6. Case Definition .................................................................................................................. 130
5.2.7 Variables ............................................................................................................................. 130
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5.2.8 Data Analysis...................................................................................................................... 131
5.2.9 Data Management and Ethical Considerations................................................................... 132
5.3. RESULTS ................................................................................................................................ 132
5.3. 1. Patient Recruitment .......................................................................................................... 132
5.3.2. Socio-Demographic Traits of Neurosurgical Patients ....................................................... 134
5.3.3. Causes of trauma among the study participants ................................................................ 135
5.3.4. Patterns of Injury and Diagnostic findings ........................................................................ 136
5.3.5. Incidence of Surgical Site Infections ................................................................................. 137
5.3.6 Comparison of the Demographic Traits of Patients who developed infection and those
who did not .................................................................................................................... 138
5.3.7 Patterns of Injury and Development of Surgical Site Infections ........................................ 139
5.3.8 Patterns of Antimicrobial Prophylaxis ............................................................................... 140
5.3.9. Effect of Antimicrobial Prophylaxis on Risk of Surgical Site Infections ......................... 141
5.3.10. Risk Factors for Surgical Site Infections- Logistic Regression Analysis........................ 141
5.3.11. Risk of Infection in Patients with Epidural Haematoma ................................................. 143
5.3.12. Determinants of the Effectiveness of Antimicrobial Prophylaxis – Effect Measure
Modification................................................................................................................... 144
5.3.13. Effect of Type of Surgical Procedures on Effectiveness of Antimicrobial Prophylaxis . 146
5.3.14. The effect of number of surgical procedures on effectiveness of antimicrobial
prophylaxis..................................................................................................................... 147
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