Surgical-site infections remain a significant contributor to hospitalacquired infections despite continued efforts to reduce their occurrence. Infection at the operative site is associated with high morbidity, mortality and prolonged hospitalisation. Typically, in neurosurgical cases the infection rate varies between 1 and 4%. While antibiotic use,¹ enhanced patient homeostasis (e.g. with respect to serum glucose levels or body temperature) and wound management are appropriate topics and are analysed in reviews on the prevention of surgical-site infections,² pre-operative antisepsis is less frequently considered.³

The rise in antimicrobial resistance makes pre-operative methods to reduce surgical-site infection even more important,^4,5 particularly since hospitalised patients tend to have a higher frequency of resistant organisms.^6,7 The rise in methicillin-resistant Staphylococcus aureus (MRSA) infections has made antibiotic prophylaxis of this highly virulent organism more difficult.⁸ This article considers the role of pre-operative antisepsis, which aims to reduce bacterial density in the operative site. The development of a sterile surface concept as part of an approach to reducing surgical-site infection in a neurosurgical setting is also reviewed.

Neurosurgery has several unique features associated with the problem of surgical-site infection: transmissible diseases, hair removal and indwelling devices. Transmissible diseases, such as spongioform encephalopathy, or transmissible viruses represent a threat to medical staff that is unique to surgery involving the central nervous system. As such, a separate focus on procedures and management of clinical issues, such as blood exposure and sterilisation procedures, is required.⁹ However, the same principles that apply to surgical-site infections generally apply to neurosurgery as well. The major source of infection is endogenous organisms found on the patient’s skin,^4,10 and the risk of infection is a balance between patient factors that resist infection and bacterial factors that encourage infection, i.e. bacterial density at the wound site and bacterial virulence.¹¹

However, these factors ignore other influcences on infection, e.g. operative time. The relative risk of infection in clean surgeries of less than two hours’ duration has been shown in a recent study to be 12.6%, and this risk doubles to 24.3% in surgeries of more than three hours’ duration. Resistance to infection is further compromised by the use of implanted devices, since it is generally recognised that the presence of a foreign material reduces the host’s capacity to resist pathogens.

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