Duration of single-agent perioperative antibiotic prophylaxis and postoperative meningitis after endoscopic endonasal skull base surgery: a systematic review and meta-analysis of 7,981 patients

Postoperative meningitis is a rare but serious complication in endoscopic-endonasal skull-base surgery. Although prophylactic antibiotics are routinely administered, the optimal regimen and duration remain unclear. This systematic review and meta-analysis evaluated the incidence of meningitis and intraoperative cerebrospinal fluid (CSF) leakage associated with single-agent perioperative antibiotic prophylaxis. Following PRISMA 2020 guidelines, PubMed, EMBASE, and Web of Science were searched through February 2025. Eligible studies reported postoperative meningitis or intraoperative cerebrospinal fluid (CSF) leak after endoscopic endonasal skull-base surgery using a single primary prophylactic antibiotic. Antibiotic duration was classified as ultra-short (≤ 1 day), short (1-3 days), or long (> 3 days). Study-level proportions were synthesized using logit-transformed random-effects models with restricted maximum likelihood estimation. Meta-regression assessed antibiotic duration and the proportion of intraoperative CSF leaks. Fourteen studies contributed and 7,981 patients were included. The pooled postoperative meningitis incidence was 1.38% (95% CI: 0.92%-2.08%; I² = 65.8%). Among protocols that could be uniquely assigned to a duration subgroup, pooled incidences were 2.12% for long-duration prophylaxis (95% CI: 0.82%-5.36%), 1.20% for short-duration prophylaxis (95% CI: 0.38%-3.70%), and 1.24% for ultra-short prophylaxis (95% CI: 0.66%-2.32%), without a significant subgroup difference (p = 0.764). Antibiotic duration was not associated with meningitis in meta-regression (p = 0.487), whereas a higher study-level proportion of intraoperative CSF leak was associated with higher meningitis incidence (β = 0.0389 per percentage point on the logit scale; p = 0.010). Postoperative meningitis was uncommon across the included cohorts. No statistically significant association was detected between prophylaxis duration and meningitis, whereas a higher intraoperative CSF leak prevalence was associated with higher meningitis incidence. These findings suggest that operative risk characteristics may be important determinants of postoperative infection risk after endoscopic endonasal skull-base surgery.