Methicillin-resistant Staphylococcus Aureus Surgical Site Infections Research Articles

History of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection may not be a contraindication to ventral hernia repair with synthetic mesh: a preliminary report

A history of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection presents a significant surgical dilemma as to the risk of subsequent mesh infection, even if no active infection is present. We investigated the outcomes of ventral hernia repair with synthetic mesh in patients with prior MRSA surgical site infections (SSIs). All patients with a clean wound but prior MRSA SSI undergoing open ventral hernia repair with mesh by a single surgeon over a 3-year period were reviewed for the development of any major (need for readmission, operative debridement, or mesh removal) or minor SSI. All patients received peri-operative intravenous vancomycin and prolonged suppressive oral trimethoprim/sulfamethoxazole or doxycycline. Ten patients (male = 7, female = 3) with clean wounds and a history of MRSA SSI underwent open ventral hernia repair with retrorectus synthetic mesh placement. Mean follow-up was 13.5 ± 3.3 months. Overall, two patients (20 %) developed SSIs (minor = 2, major = 0). Both SSIs were successfully managed with therapeutic oral antibiotics and local wound care without need for surgical debridement or mesh removal. There have been no hernia recurrences in any of the patients. Preliminary results suggest that history of MRSA infection may not be a contraindication to the use of synthetic mesh for ventral hernia repair. Macroporous lightweight meshes, combined with use of prolonged suppressive antibiotics and sublay retromuscular mesh placement that provides complete tissue coverage, should be further investigated as an acceptable prosthetic choice when planning a complex ventral hernia repair in the setting of prior MRSA SSI.

Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin

Surgical site infections (SSIs) associated with methicillin-resistant Staphylococcus aureus (MRSA) are a major complication of surgery. This study is part of a large infection control quality improvement effort to eliminate MRSA SSIs. This is an Institutional Review Board-approved, case-control study examining MRSA SSI rates before and after implementation of a facility-wide MRSA SSI prevention protocol in 2007. The protocol involved a 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths. In 2006, a total of 39 MRSA SSIs occurred after 9,976 procedures in patients who underwent orthopedic, vascular, cardiac, or neurosurgical procedures (rate=0.39 per 100 procedures). The highest incidence occurred after cardiac surgery (rate=1.24/100 procedures), and the lowest occurred after orthopedic surgery (rate=0.28/100 procedures). In 2007, the MRSA SSI rate decreased to 20 of 9,818 procedures (rate=0.20/100 procedures) in the 4 categories (P=.016; odds ratio, 1.92). In 2008, the MRSA SSI rate dropped again to 13 of 10,068 procedures (rate=0.13/100 procedures) in the 4 categories (P=.0003; odds ratio, 3.04). A 5-day course of intranasal mupirocin and nonrinse 2% chlorhexidine gluconate cloths may be beneficial in preventing MRSA SSIs in the non-general surgery population.

Epidemiology of Methicillin-Resistant Staphylococcus aureus Carriage and MRSA Surgical Site Infections in Patients Undergoing Colorectal Surgery: A Cohort Study in Two Centers

Surgical site infections (SSIs) after colorectal surgery usually are caused by commensal intestinal bacteria. Methicillin-resistant Staphylococcus aureus (MRSA) may be responsible for additional SSI-related morbidity. The aim of this retrospective cohort study was to describe the epidemiology of SSIs caused by MRSA after colorectal surgery in two tertiary-care centers, one in Geneva, Switzerland (G), and the other in Chicago, Illinois (C). Adult patients undergoing colorectal resections during periods of universal screening for MRSA on admission were identified retrospectively. Demographic characteristics, surgery-related factors, and occurrence of MRSA SSI were compared in patients with and without MRSA carriage before surgery. There were 1,069 patients (G=194, C=875) with a median age of 67 years fulfilling the inclusion criteria. Of these, 45 patients (4.2%) had a positive MRSA screening result within 30 days before surgery (G=18, C=27; p<0.001). Ten patients (0.9%; G=6, C=4) developed MRSA SSI, detected a median of 17.5 days after surgery, but only two of them were MRSA-positive before surgery. Nine of the 45 MRSA carriers identified by screening received pre-operative prophylaxis with vancomycin (G 6/18, C 3/27), and 17 of these patients (37.8%; G 7/18, C 10/27) were started on MRSA decolonization therapy before surgery. Pre-operative administration of either decolonization or vancomycin was not protective against MRSA SSI (p=0.49). Methicillin-resistant S. aureus seems to be an infrequent cause of SSI after colorectal resections, even in MRSA carriers. Systematic universal screening for MRSA carriage prior to colorectal surgery may not be beneficial for the individual patient. Post-operative factors seem to be important in MRSA infections, as the majority of MRSA SSIs occurred in patients negative for MRSA carriage.

Factors Associated with Post-Operative Conversion to Methicillin-ResistantStaphylococcus AureusPositivity or Infection in Initially MRSA-Negative Patients

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) is associated with morbid, invasive infections and has been implicated in nearly every type of nosocomial infection. Our aim was to identify the risk factors for patient conversion from MRSA negativity pre-operatively to MRSA positivity post-operatively. We retrospectively reviewed all patients at the Veterans Affairs-Boston Health Care System who underwent clean or clean-contaminated surgical procedures during the years 2008 and 2009 and had documented pre-operative nasal polymerase chain reaction (PCR) testing for MRSA. We abstracted post-operative MRSA microbiologic testing results, MRSA infections, surgical site infections (SSIs), surgical prophylaxis data, and SSI risk index, as calculated using the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database variables. All patients who had a negative nasal MRSA PCR result in the 31-day pre-operative period and did not have any positive MRSA clinical swab or culture in the 1-year pre-operative period were defined as MRSA-negative. These patients were classified as converters to MRSA positivity if they had at least one documented positive nasal MRSA PCR swab, culture, nosocomial infection, or SSI within 31 days post-operatively. Among 4,238 eligible patients, 3,890 (92%) qualified as MRSA-negative pre-operatively. A total of 1,432 (37%) of these patients were assessed in the VASQIP database, of whom 34 (2%) converted to MRSA positivity post-operatively. On multivariable logistic regression analysis of the VASQIP sample, age (odds ratio [OR] 1.049; 95% confidence interval [CI] 1.016, 1.083), SSI risk index (OR 2.863; 95% CI 1.251-6.554), and vancomycin prophylaxis alone or in combination (OR 3.223; 95% CI 1.174-8.845) were significantly associated with conversion to MRSA positivity. In pre-operatively MRSA-negative patients, age, SSI risk index, and vancomycin prophylaxis were significant factors for conversion to MRSA positivity post-operatively. Alternatives to vancomycin prophylaxis in non-colonized patients and optimization of patients' SSI risk factors should be considered before elective surgery.

Soft tissue and bone MRSA infections

A great percentage of orthopaedic patients are elderly people who attend the A/E department usually having sustained a proximal femur fracture after a minor mechanical fall. Many of these patients reside in residential or nursing homes. These patients are generally in poorer health in comparison with those living independently, and are prone to post-operative wound infections. Post-operative wound infections due to methicillin-resistant Staphylococcus aureus (MRSA) continue to be a major concern to clinicians and the public, and to the commissioners and providers of health care. In particular, orthopaedic trauma surgery is a surgical specialty which uses a great variety of implants to treat skeletal injury. Once bacteria, either seeded during the open surgery or carried by the bloodstream, adhere on the implant surface they become very difficult to eradicate. MRSA is implicated in up to 30–50% of all post-operative surgical infections in trauma and orthopaedic surgery. MRSA has been an increasing problem since its isolation in England in 1961. It is easily transmissible from one person to another. MRSA infection can be endogenous (from the patient’s own resident MRSA) or exogenously acquired, by cross-infection from either an asymptomatic carrier or a patient with MRSA infection. MRSA infections result in an increased hospital stay, increased risk for other hospitalised patients and in great financial cost of treatment, due to implementation of further treatment methods, longer need for IV antibiotics, closer patient monitoring and additional surgical intervention. Bloodstream invasion by MRSA can lead to septicaemia, which is associated with 10–20% mortality. The publicity surrounding MRSA has never been greater. The introduction by the Department of Health in the United Kingdom of mandatory surveillance schemes for both MRSA bacteraemia and surgical site infection (SSI) in orthopaedic surgery from 2001 and 2004, respectively, highlights the importance of nosocomial infection. Surveillance of bacteraemia caused by MRSA in the UK has involved collection of data from hospital microbiology laboratories via several mechanisms. These include a voluntary reporting scheme that has been operational in England and Wales since 1989 and mandatory reporting schemes that have been running independently in England, Wales, Scotland and Northern Ireland since 2001. Another surveillance scheme is also available that was created by participating sentinel laboratories that submit isolates for centralised susceptibility testing (Bacteraemia Resistance Surveillance Programme run by the BSAC).

Preoperative Nasal Methicillin-Resistant Staphylococcus aureus Status, Surgical Prophylaxis, and Risk-Adjusted Postoperative Outcomes in Veterans

To determine whether preoperative nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage is a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis. Retrospective cohort study. Veterans Affairs (VA) Boston patients who had nasal MRSA polymerase chain reaction screening performed in the 31 days before clean or clean contaminated surgery in 2008-2009. Postoperative MRSA clinical cultures and infections, total surgical site infections (SSIs), and surgical prophylaxis data were abstracted from administrative databases. MRSA infections were confirmed via chart review. Multivariate analysis of risk factors for each outcome was conducted using Poisson regression. SSI risk index was calculated for a subset of 1,551 patients assessed by the VA National Surgical Quality Improvement Program. Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. Postoperative MRSA clinical cultures and infections, including MRSA SSIs, were each significantly increased in patients with preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA remained significantly associated with postoperative MRSA cultures (relative risk [RR], 8.81; 95% confidence interval [CI], 3.01-25.82) and infections (RR, 8.46; 95% CI, 1.70-42.04). Vancomycin prophylaxis was associated with an increased risk of total SSI in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19-8.57) but not in patients positive for nasal MRSA. In our population, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures and infections in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients.

Importance of Methicillin-Resistant Staphylococcus aureus Eradication in Carriers to Prevent Postoperative Methicillin-Resistant Staphylococcus aureus Surgical Site Infection

Although infrequent, postoperative methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection (SSI) is associated with significant morbidity and cost. Previous studies have identified the importance of MRSA screening to diminish the risk of postoperative MRSA SSI. The current study quantifies the importance of eradication of the MRSA carrier state to prevent MRSA SSI. Beginning February 2007, all admissions to an 800-bed tertiary care hospital were screened for MRSA by nasal swab using rapid polymerase chain reaction-based testing. Patients found to be nasal carriers of MRSA were treated with 2 per cent mupirocin nasal ointment and 4 per cent chlorhexidine soap before surgery. The subset of patients undergoing procedures that are part of the Surgical Care Improvement Project (SCIP) were followed for MRSA SSI (n = 8980). The results of preoperative MRSA screening and eradication of the carrier state were analyzed. Since the initiation of universal MRSA screening, 11 patients undergoing SCIP procedures have developed MRSA SSI (0.12%). Of these, six patients (55%) had negative preoperative screens. Of the five patients with positive preoperative screens, only one received treatment to eradicate the carrier state. In patients who develop MRSA SSI, failure to treat the carrier state before surgery results in MRSA SSI.

Universal MRSA Nasal Surveillance: Characterization of Outcomes at a Tertiary Care Center and Implications for Infection Control

Recognition of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage by active surveillance cultures has been widely debated. Our institution implemented universal nasal screening by polymerase chain reaction (PCR) for MRSA and isolation of screen positive patients in December 2007. Here we present data about the correlation between screen positivity and subsequent development of infection and the impact of isolation on surgical site infection rates. This was a retrospective, observational study from January 1, 2008, through June 30, 2008, on all inpatient admissions with a nasal MRSA PCR screen. Genotype of 15 MRSA blood isolates was determined utilizing the Diversilab® (bioMérieux, Hazelwood, MO) system. A phenotypic rule was deduced and utilized for analyzing all MRSA clinical isolates. 5375 patients were screened at ≤48 hours following admission. 581 MRSA positive nasal carriers (10.80%) were identified. 496 (85.3%) were asymptomatic MRSA nasal carriers. There were a total of 158 MRSA clinical infections. 85 (14.6%) MRSA nasal carriers had clinical infection. Of the 4794 (89.1%) non-nasally colonized patients, 73 (1.5%) had MRSA clinical infection. MRSA surgical site infection rate remained unchanged during the intervention period. Phenotypic predictive rule inferred 59.8% community-acquired MRSA (CA-MRSA) infections and 40% hospital-acquired MRSA (HA-MRSA) infections. Our study showed a positive correlation between having a nasal screen positivity and subsequent development of infection. Isolation of MRSA screen positive patients alone as an intervention did not reduce the surgical site infection rates. Since most of our isolates are CA-MRSA, our institution is implementing several new interventions to further reduce the incidence of HA-MRSA conditions.

Glycopeptide vs. Non-Glycopeptide Antibiotics for Prophylaxis of Surgical Site Infections: A Systematic Review

Patients receive prophylactic antibiotics against surgical site infections (SSIs) before or during many procedures. Glycopeptide antibiotics are effective against most strains of methicillin-resistant Staphylococcus aureus (MRSA), but their wider use risks increasing resistance. Our objective was to review the evidence for clinical effectiveness that might help to determine whether there is a threshold of MRSA prevalence at which switching from non-glycopeptide to glycopeptide antibiotic prophylaxis might be justified. We performed a systematic review of randomized trials comparing a glycopeptide with an alternative antibiotic regimen for SSI prophylaxis in adults undergoing clean or clean-contaminated surgical procedures. The evidence was used to inform development of a decision-analytic model. We subsequently updated the review to May 2008. Fourteen studies were identified that provided evidence concerning clinical effectiveness. The studies were too heterogeneous clinically for meta-analysis. Only one of 12 trials found that glycopeptides reduced SSIs significantly at 30 days compared with non-glycopeptide antibiotics. Of the two trials that reported on MRSA infection, neither found a significant difference between glycopeptide and comparator drugs. This systematic review did not find any evidence to support the use of glycopeptides in preference to other antibiotics for the prevention of MRSA infections and SSIs. The limitations of the evidence make it difficult to identify a threshold at which a switch from non-glycopeptide to glycopeptide prophylaxis should be recommended. Given the difficulties of addressing this issue through randomized trials, further research should focus on hospital infection control policies, MRSA screening, and the isolation and treatment of anyone infected with MRSA prior to surgery.

Reducing Surgical Site Infections by Bundling Multiple Risk Reduction Strategies and Active Surveillance

Postoperative surgical site infections (SSIs) are serious health care-associated infections that contribute to higher rates of mortality. Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of SSIs. A quality improvement intervention was developed to identify surgical patients with nasal colonization of MRSA, treat them with mupirocin, and introduce a new preoperative skin antisepsis protocol using 2% chlorhexidine gluconate cloths. The total number of SSIs was reduced by 63%, and MRSA SSIs decreased by 78%. Preoperative MRSA screening and treatment and the preoperative skin antisepsis protocol were smoothly integrated into the facility workflow and well accepted by patients. This intervention saved two community hospitals an estimated $240,000.

Poor Functional Status Is an Independent Predictor of Surgical Site Infections Due to Methicillin‐Resistant Staphylococcus aureus in Older Adults

Methicillin-resistant Staphylococcus aureus (MRSA) has become a common surgical site infection (SSI) pathogen, particularly in older adults. Risk factors for MRSA SSI in elderly patients have not been described. A nested case-control study was conducted. Patients were enrolled from seven study hospitals (one medical center and six community hospitals) between January 1, 1998, and April 1, 2003. Risk factors for MRSA SSI were identified by comparing cases with two reference groups: uninfected surgical patients and patients with SSI due to methicillin-susceptible S. aureus (MSSA). Two separate multivariate models were created using logistic regression and then compared and contrasted. Eighty-six patients with MRSA and 64 with MSSA SSI were identified. One hundred sixty-seven uninfected surgical patients were selected. In multivariate analysis using uninfected surgical patients as controls, requiring assistance in three or more activities of daily living (ADLs) was an independent risk factor for MRSA SSI (odds ratio (OR)=2.73, 95% confidence interval (CI)=1.16-6.46). Using patients with MSSA SSIs as a reference group, requiring assistance in three or more ADLs was also a significant predictor for MRSA SSI (OR=3.78, 95% CI=1.43-9.98) in multivariate analysis. Other independent predictors included Charlson score, wound class, and surgical duration. Lack of independence in ADLs was an independent risk factor for MRSA SSI in elderly patients in both models. Poor functional status (requiring assistance in >or=3 ADLs) was specifically associated with MRSA SSI. Functional status is an objective, readily available variable that can be used to stratify patients at risk for MRSA SSI.

Characteristics and Outcomes of Methicillin-Resistant Staphylococcus aureus Surgical-Site Infections in Patients with Cancer: a Case–Control Study

Methicillin-resistant Staphylococcus aureus (MRSA) infections remain a significant cause of morbidity and mortality. We experienced an increased incidence of MRSA surgical-site infections (MRSA SSIs) at our institution. However, to our knowledge, no studies have evaluated the risk factors and outcomes of MRSA SSIs in cancer patients. We conducted a case-control study and identified all patients who had developed MRSA SSIs at our institution from July 1, 2002 to July 30, 2003, and all patients who had undergone surgery by the same surgical team during the same time period but who had not developed MRSA SSIs. Cases and controls were age-matched at 1:2 ratio. The study included 29 cases and 58 controls. Mean interval between surgery and MRSA SSI onset was 17.8 days (range 3-75 days). Cases were more likely than controls to have progressive cancer (72 versus 38%), have received antibiotics (mainly quinolones) within 24 h of surgery (17 versus 2%), have had ongoing infection (10 versus 0%), and have had longer hospital and intensive care unit stays (11.0 versus 7.8 days and 3.4 versus 1.5 days) (all P < 0.05). In a multivariate logistic regression analysis, significant predictors of MRSA SSI in cancer patients were antibiotics use <24 h of surgery and progressive cancer. No surgical factors (i.e., procedure time or timing of perioperative antibiotics) were associated with increased risk of MRSA SSI. Several clinical and postoperative factors were associated with increased risk of MRSA SSI in cancer patients, but antibiotic use before surgery (especially quinolones) and progressive cancer were the only independent predictors.

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections

Background Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs) increase morbidity and mortality. We examined the impact of the MRSA bundle on SSIs. Methods Data regarding the implementation of the MRSA bundle from 2007 to 2008 were obtained, including admission and discharge MRSA screenings, overall MRSA infections, and cardiac and orthopedic SSIs. Chi-square was used for all comparisons. Results A significant decrease in MRSA transmission from a 5.8 to 3.0 per 1,000 bed-days ( P < .05) was found after implementation of the MRSA bundle. Overall MRSA nosocomial infections decreased from 2.0 to 1.0 per 1,000 bed-days ( P = .016). There was a statistically significant decrease in overall SSIs ( P < .05), with a 65% decrease in orthopaedic MRSA SSIs and 1% decrease in cardiac MRSA SSIs. Conclusion Our data demonstrate that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs.

Functional Status Assessment in the Preoperative Evaluation of Older Adults

MANY COMMON SURGICAL PROCEDURES SUCH AS spinal fusion, coronary artery bypass grafting, and arthroplasty are routinely performed on older adults. Although such procedures can enhance quality and duration of life, adverse events related to the procedure and postoperative period are key considerations. Important complications include delirium, infection, and cardiac events. Development of these and other complications are associated with increased length of stay, increased rate of discharge to chronic care facilities, and increased mortality. Although age has been considered a primary predictor of surgical outcomes, preoperative functional status is likely a better surrogate for postoperative risk. Delirium is a major concern for older patients. Although risk factors for postoperative delirium are well defined, relatively few patients receive targeted interventions for prevention. If preoperative evaluation helped identify patients with poor functional status (cognitive and physical impairment predicts delirium), these individuals might benefit from specific environmental and pharmacologic interventions. Although some institutions have addressed delirium prevention in a proactive, multidisciplinary manner, wide-scale implementation lags. Another important complication is surgical site infection (SSI). Besides increases in length of stay and health care costs associated with SSI, treatment can require additional surgical procedures and extended antimicrobial therapy. The resulting immobility often contributes to poor functional outcomes, thereby potentially reducing any palliative benefit of surgery. Even though age has been recognized as a risk factor for infection, the association has traditionally been attributed to immune senescence and patient comorbidities. Compelling evidence for a link between impaired functional status and SSI was recently demonstrated by Anderson et al, who reviewed 141 345 operative procedures, examining risk factors for the development of methicillin-resistant Staphylococcus aureus (MRSA) SSI. The need for assistance with 3 or more activities of daily living (ADLs) was independently associated with an increased risk of MRSA SSI, an association that persisted after stratifying patients by age. Despite increasing evidence suggesting that impaired functional status is associated with poor postoperative outcomes, the exact connection remains elusive. For instance, development of MRSA SSI is often preceded by MRSA colonization. Yet among older adults who develop SSI, it is unclear whether these patients are colonized with MRSA prior to their operation because of previous health care exposure or whether poor functional status results in increased length of stay and MRSA exposure postoperatively. Although decolonization strategies have been explored for SSI prevention, randomized studies have failed to show consistent benefit. As the number of older adults undergoing major operative procedures continues to increase, several critical changes must occur to address the care needs of this expanding population.

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant Staphylococcus aureus

Fatal Septic Thrombosis of the Superior Sagittal Sinus After Face-lift Surgery Caused by Community-Associated Methicillin-Resistant <i>Staphylococcus aureus</i>

Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit

We examined the incidence of infection with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the Leicester Royal Infirmary Trauma Unit between January 2004 and June 2006. The influence of MRSA status at the time of their admission was examined, together with age, gender and diagnosis, using multi-variant analysis. Of 2473 patients, 79 (3.2%) were MRSA carriers at the time of admission and 2394 (96.8%) were MRSA-negative. Those carrying MRSA at the time of admission were more likely to develop surgical site infection with MRSA (7 of 79 patients, 8.8%) than non-MRSA carriers (54 of 2394 patients, 2.2%, p < 0.001). Further analysis showed that hip fracture and increasing age were also risk factors with a linear increase in relative risk of 1.8% per year. MRSA carriage at admission, age and the pathology are all associated with an increased rate of developing MRSA wound infection. Identification of such risk factors at admission helps to target health-care resources, such the use of glycopeptide antibiotics at induction and the 'building-in' of increased vigilance for wound infection pre-operatively.

Risk Factors for Methicillin-ResistantStaphylococcus aureusSurgical Site Infection

We prospectively evaluated 46 possible risk factors for methicillin-resistant Staphylococcus aureus (MRSA) surgical site infection (SSI) among patients with MRSA carriage in a large intervention study. Of 6,130 study patients, 68 (1.1%) developed MRSA SSI, which occurred a median of 14 days after surgery. Risk factors associated with MRSA SSI were receipt of emergency surgery, presence of comorbid condition, receipt of immunosuppressive therapy, receipt of contaminated surgery, and a surgical duration longer than the 75th percentile. MRSA carriage on admission did not predict MRSA SSI.

Efficacy of Pre-Operative MRSA Screening in Otolaryngology

Objective To examine the efficacy of pre-operative Staphylococcus aureus screening by nasal swab on post-operative Methicillin-resistant Staphylococcus aureus (MRSA) infection rates in surgical patients undergoing varied otolaryngological procedures. Methods Retrospective review of MRSA colonization and infection rates in surgical otolaryngology patients at a single institution. MRSA infection rates in unscreened patients undergoing procedures during a one-year period were compared to infection rates in patients undergoing pre-operative Staphylococcus aureus screening in an 11-month time frame. Patients colonized with Staphylococcus aureus were treated with Mupirocin and Chlorhexidine prior to the procedure. Results Records of 420 patients undergoing varied otolaryngological procedures were evaluated. In the 241 patients without pre-operative screening, 9 patients had Staphylococcus aureus-infected wounds. There were two (0.83%) post-operative MRSA surgical site infections. Out of 179 patients followed after screening was initiated, 24 patients (13.4%) were colonized with Staphylococcus aureus and underwent preoperative treatment. There were no MRSA infections in the post-operative period. Conclusions Early results demonstrate the potential benefit of pre-operative Staphylococcus aureus screening in reducing the MRSA infection rate. Screening and treatment of MRSA colonized patients pre-operatively reduces infectious complications and should be considered in otolaryngology surgical practice.

Universal Screening for Methicillin-Resistant &lt;emph type="ital"&gt;Staphylococcus aureus&lt;/emph&gt; at Hospital Admission and Nosocomial Infection in Surgical Patients

Experts and policy makers have repeatedly called for universal screening at hospital admission to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. To determine the effect of an early MRSA detection strategy on nosocomial MRSA infection rates in surgical patients. Prospective, interventional cohort study conducted between July 2004 and May 2006 among 21 754 surgical patients at a Swiss teaching hospital using a crossover design to compare 2 MRSA control strategies (rapid screening on admission plus standard infection control measures vs standard infection control alone). Twelve surgical wards including different surgical specialties were enrolled according to a prespecified agenda, assigned to either the control or intervention group for a 9-month period, then switched over to the other group for a further 9 months. During the rapid screening intervention periods, patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid, multiplex polymerase chain reaction. For both intervention (n=10 844) and control (n=10 910) periods, standard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers, use of dedicated material (eg, gown, gloves, mask if indicated), adjustment of perioperative antibiotic prophylaxis of MRSA carriers, computerized MRSA alert system, and topical decolonization (nasal mupirocin ointment and chlorhexidine body washing) for 5 days. Incidence of nosocomial MRSA infection, MRSA surgical site infection, and rates of nosocomial acquisition of MRSA. Overall, 10 193 of 10 844 patients (94%) were screened during the intervention periods. Screening identified 515 MRSA-positive patients (5.1%), including 337 previously unknown MRSA carriers. Median time from screening to notification of test results was 22.5 hours (interquartile range, 12.2-28.2 hours). In the intervention periods, 93 patients (1.11 per 1000 patient-days) developed nosocomial MRSA infection compared with 76 in the control periods (0.91 per 1000 patient-days; adjusted incidence rate ratio, 1.20; 95% confidence interval, 0.85-1.69; P = .29). The rate of MRSA surgical site infection and nosocomial MRSA acquisition did not change significantly. Fifty-three of 93 infected patients (57%) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization. A universal, rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection. isrctn.org Identifier: ISRCTN06603006.

Surgical Site Infection After Surgery to Repair Femoral Neck Fracture: A French Multicenter Retrospective Study

Femoral neck fracture is the most frequent orthopedic emergency among elderly persons. Despite a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) carriage in this population, no multicenter study of antibiotic prophylaxis practices and the rate and microbiological characteristics of surgical site infection (SSI) has been performed in France. Retrospective, multicenter cohort study. Twenty-two university and community hospitals in France. Each center provided data on 25 consecutive patients who underwent surgery for femoral neck fracture during the first quarter of 2005. Demographic, clinical, and follow-up characteristics were recorded, and most patients had a follow-up office visit or were involved in a telephone survey 1 year after surgery. These 22 centers provided data on 541 patients, 396 (73%) of whom were followed up 1 year after surgery. Of 504 (93%) patients for whom antibiotic prophylaxis was recorded, 433 (86%) received a cephalosporin. Twenty-two patients had an SSI, for a rate of 5.6% (95% confidence interval, 3.7-8.0). SSI was reported for 15 (6.9%) of patients who had a prosthesis placed and for 7 (3.9%) who underwent osteosynthesis (P=.27). SSI was diagnosed a median of 30 days after surgery (interquartile range, 21-41 days); 7 (32%) of these SSIs were superficial infections, and 15 (68%) were deep or organ-space infections. MRSA caused 7 SSIs (32%), Pseudomonas aeruginosa caused 5 (23%), other staphylococci caused 4 (18%), and other bacteria caused 2 (9%); the etiologic pathogen was unknown in 4 cases (18%). Reoperation was performed for 14 patients with deep or organ-space SSI, including 6 of 7 patients with MRSA SSI. The mortality rate 1 year after surgery was 20% overall but 50% among patients with SSI. In univariate analysis, only the National Nosocomial Infections Surveillance System risk index score was significantly associated with SSI (P=.006). SSI after surgery for femoral neck fracture is severe, and MRSA is the most frequently encountered etiologic pathogen. A large, multicenter prospective trial is necessary to determine whether the use of antibiotic prophylaxis effective against MRSA would decrease the SSI rate in this population.