Operative Planning

• Review imaging studies
  
  
  
  
  • Computed tomography or magnetic resonance imaging with or without contrast useful in delineating extent of infection
  
  
• To guide antibiotic therapy, culture blood, urine, sputum, cerebrospinal fluid, and wound drainage
  
• Surgical intervention usually required
  
• For spontaneous lesions, look for predisposing factors such as immunosuppression and for a source, such as sinusitis or sepsis
  
• Obtain baseline white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels

Spontaneous Infections

• Plan craniotomy for access to entire lesion
  
• Ensure scalp flap has adequate blood supply given underlying infection
  
• Craniotomy should easily allow for reoperation if needed
  
• Send intraoperative cultures to laboratory as these are the most reliable to guide antibiotic therapy

Postoperative Infections

• Plan for possible extension of prior incision for additional access to lesion
  
• Remove existing sutures/staples prior to skip preparation
  
• Recent incisions may be opened using blade, scissors, and hemostat
  
• If bone flap is to be replaced, scrub vigorously and consider bathing bone in Betadine
  
• Bone flap removed if infected
  
• Send intraoperative cultures to laboratory as these are the most reliable to guide antibiotic therapy

Débridement and Irrigation

• Débride/remove infected tissue
  
• Irrigate copiously with antibiotic containing irrigation. Pulse lavage may be useful.

• Avoid foreign bodies
  
• Use Jackson-Pratt or other drains. Remove when output low and/or wound appears to be healing well.
  
• Close scalp with monofilament in single layer; for example, 3–0 nylon interrupted or vertical mattress sutures

• Infectious disease consult often useful to help guide antibiotic therapy and outpatient follow-up
  
• Long-term intravenous antibiotics often needed (6 to 12 weeks), so consider tunneled central line or peripherally inserted central catheter line
  
• Monitor complete blood count, ESR, and CRP for response to therapy
  
• Sutures kept in place at least 10 to 14 days and longer for multiple surgeries
  
• Re-image as necessary, especially in patients who are not improving
  
• Cranioplasty for patients without bone flap, often several weeks later after infection cleared