title: Clinical, radiological, and microbiological profile of patients with autogenous cranioplasty infections.
abstract: OBJECTIVE
  Bone flap infections after autogenous cranioplasty can present a diagnostic and management challenge. Little is known about the clinical, radiological, and microbiological profile of these patients.
  
  
  METHODS
  Patients who developed bone flap infective complications requiring explantation after autogenous cranioplasties between 1999 and 2009 were identified. Their prospectively collected demographic details, clinical presentation, radiological features, surgical intervention, microbiological profile, and treatment outcomes were retrospectively reviewed.
  
  
  RESULTS
  During the study period, 179 cranioplasties were performed with frozen autogenous skull flaps. Seventeen patients (10%, median age 25 years) experienced deep infections that necessitated flap removal and antimicrobial treatment. Although fever, swelling of the scalp, and local inflammation were present in majority of patients (76.5%), inflammatory markers were abnormal only in 33%. Computed tomography imaging features included extra-axial collection (76.5%), subgaleal collection or galeal swelling (70.6%), cerebritis (37.5%), and osteomyelitis (23.5%). Positive bacterial cultures were obtained from all (100%) explanted bone flaps, including gram-positive (82.3 %) and -negative (17.7%) organisms. A significant proportion (29.4%) of patients presented with complications late during follow-up (>6 weeks); 60% of these were attributable to Propionibacterium acnes infection.
  
  
  CONCLUSIONS
  Clinical assessment is critical to the diagnosis of bone-flap infection. A high index of suspicion is necessary because late presentations are possible. Empirical antimicrobial treatment should include gram-negative coverage.
authors.affiliation: Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia. Electronic address: ivanbpaul@gmail.com.
authors.forename: Ivan P
authors.initials: IP
authors.lastname: Bhaskar
authors.affiliation: Division of Microbiology and Infectious Diseases, PathWest Laboratory Medicine WA, QE II Medical Centre, Nedlands, Western Australia, Australia; School of Pathology & Laboratory Medicine, Faculty of Medicine & Dentistry, University of Western Australia, QE II Medical Centre, Nedlands, Western Australia, Australia.
authors.forename: Timothy J J
authors.initials: TJ
authors.lastname: Inglis
authors.affiliation: Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; School of Surgery, Faculty of Medicine & Dentistry, University of Western Australia, QE II Medical Centre, Nedlands, Western Australia, Australia.
authors.forename: Gabriel Y F
authors.initials: GY
authors.lastname: Lee
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003399:Craniotomy / Q000009:adverse effects*; D016908:Gram-Positive Bacterial Infections / Q000000981:diagnostic imaging / Q000382:microbiology / Q000628:therapy; D006801:Humans; D011425:Propionibacterium acnes; D012307:Risk Factors; D013524:Surgical Flaps / Q000382:microbiology / Q000601:surgery; D013530:Surgical Wound Infection / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000382:microbiology; D014057:Tomography, X-Ray Computed
chemical_list: D000900:Anti-Bacterial Agents
keywords: Autogenous cranioplasty; Bone flap; Infection; Propionibacterium acnes