Nasal Decontamination Research Articles

Prevention of surgical site infections: a personal odyssey

Prevention of surgical site infections: a personal odyssey

447: EFFICACY OF NASAL DECONTAMINATION WITH POVIDONE-IODINE COMPARED TO MUPIROCIN IN CARDIAC SURGERY

Introduction: Surgical site infections (SSIs) are considered the most common and costly healthcare-associated infection; coronary artery bypass graft (CABG) surgeries have the second highest cumulative incidence. Mupirocin is considered the gold standard intranasal decontamination treatment; however, povidone-iodine has emerged as an alternative. The objective of this study is to determine if universal nasal decontamination with povidone-iodine is as effective as targeted mupirocin in the prevention of SSIs in cardiac surgery patients. Methods: A single-center, retrospective, pre/post intervention analysis was conducted on adult patients admitted to Prisma Health–Upstate January 2017 to December 2021. Included patients received cardiac surgery for CABG and preoperative nasal decontamination with mupirocin (January 2017-December 2018) or povidone-iodine (January 2019-December 2021). The primary outcome assessed was SSI incidence. Secondary outcomes included S. aureus SSIs, non-surgical site S. aureus infection, in-hospital and 30-day mortality, hospital, and intensive care unit (ICU) length of stay (LOS), and cost. Results: Five hundred patients were screened, and 237 patients met inclusion criteria. Included patients were grouped into those receiving mupirocin (N=70) and povidone-iodine (N=167). Significant differences in baseline characteristics included the number of males and composite of past medical history. There was no difference in incidence of SSIs identified between the povidone-iodine and mupirocin (6 versus 3, p=0.726), even when stratified by SSI type (p=0.786). No differences were identified in any of the secondary outcomes between the povidone-iodine and mupirocin groups; however, evaluation of the safety outcome revealed more adverse events in the mupirocin group (p=0.025). Conclusions: This study provides evidence of efficacy and safety of povidone-iodine for preoperative nasal decontamination in cardiac surgery patients. Povidone-iodine may be considered as an alternative to mupirocin in the cardiac surgery population.

Systematic skin and nasal decolonization lowers Staphylococcus infection in pediatric cardiac surgery

Postoperative infections occur in approximately 10% of pediatric cardiac surgeries, involving Staphylococcus species in most cases. Nasal decontamination of Staphylococcus with mupirocin has been reported to reduce postoperative Staphylococcus infections after cardiac surgery in adults, but the effect of preoperative decontamination in children undergoing cardiac surgery has not been sufficiently studied to reach consensus. We conducted a single-center retrospective study to evaluate the impact of systematic preoperative decolonization with intranasal mupirocin application and skin-washing with chlorhexidine soap on postoperative Staphylococcus infection in children undergoing cardiac surgery. Our population was divided into three groups according to decolonization protocol (group N: no decolonization; group T: targeted decolonization in Staphylococcus aureus [SA] carriers only; and group S: systematic decolonization). A total of 393 children were included between October 2011 and August 2015 (122 in group N, 148 in group T, and 123 in group S). The Staphylococcus infection rate significantly decreased in group S compared to group N (0.8% vs. 7.7%; p<0.05) and tended to decrease in group S compared to group T (0.8% vs. 4.7%; p=0.06). Systematic decontamination also significantly reduced the rate of infections starting from the skin (including surgical site infections and bloodstream infections) compared to targeted decolonization or lack of decolonization, but had no effect on the rate of pulmonary infections. The results of our study suggest that systematic preoperative skin and nasal decontamination, regardless of SA carriage status, could reduce the rate of postoperative Staphylococcus infections after cardiac surgery in children.

Do Preoperative Nasal Antiseptic Swabs Reduce the Rate of Surgical Site Infections After Adult Thoracolumbar Spine Surgery?

Surgical site infection (SSI) remains a major complication after adult spinal surgery. We investigated whether adding preoperative nasal decontamination by antiseptic swab (skin and nasal antiseptic povidone-iodine, SNA-PI) to our antimicrobial protocol reduces the SSI rate among our patients undergoing thoracolumbar spinal surgery.We retrospectively reviewed all adult thoracolumbar spinal surgeries performed between June 2015 and May 2017 at a single hospital. Patients were divided into those who received nasal decontamination (SNA-PI+) and those who did not (SNA-PI-). SSI rates and responsible pathogens were compared between the cohorts.A total of 1,555 surgeries with nasal decontamination (SNA-PI+) and 1,423 surgeries without (SNA-PI-) were included. The SSI rate in the SNA-PI+ group was 13 of 1,555 (0.8%) versus 10 of 1,423 (0.7%) for SNA-PI- group (P = 0.68). The infection rate was the highest among posterior instrumented fusions in the SNA-PI+ group (1.4%). Methicillin-sensitive Staphylococcus aureus was responsible for 70% of infections in the SNA-PI- group and 38% in the SNA-PI+ group (P = 0.13).Routine nasal antiseptic swab before spine surgery did not affect the overall rate of SSI in thoracolumbar spinal surgeries. The incidence of methicillin-sensitive S aureus was lower in patients who received nasal decontamination (5/1,555, 0.3%) compared with those who did not (7/1,423, 0.5%); however, this result was not statistically significant (P = 0.57).

TOLERABILITY OF HALODINE ORAL AND NASAL ANTISEPTICS AS PART OF A SARS-COV-2 TRANSMISSION REDUCTION STRATEGY

Background: ® Halodine oral and nasal antiseptics (Halodine LLC, Miami, FL USA) have been employed for routine oral and nasal decontamination as part of SARS-CoV-2 transmission reduction protocols.These preparations designed for the mouth and nose have been developed as oral sprays (1.25% povidone-iodine solution), oral rinses (1.75% povidoneiodine solution), nasal swabsticks (2.5% povidone-iodine solution), and nasal irrigation solutions (1.25% povidoneiodine solution). Methods: In a cross-sectional survey study, individuals who used any of the Halodine nasal or oral antiseptic products as part of a SARS-CoV-2 transmission reduction protocol were consented and invited to voluntarily complete a written questionnaire based on their practice and usage. Questions were derived from the Sino-Nasal Outcome Test (SNOT-22) to capture overall comfort and nasal symptomology.Results: There were 133 individuals ages 2-86 years who used Halodine in the forms of oral sprays,oral rinse,nasal swab-sticks,and nasal irrigation solutions for oral and nasal decontamination and volunteered to complete a satisfaction survey to assess tolerability. Decontamination was well tolerated; 99.2% of respondents reported no pain and 88.0% reported no nasal symptoms. Loss of taste, loss of smell, dizziness or blocked sinuses were not reported in any individuals. Three percent of respondents reported clearing of their sinuses.Halodine oral and/or nasal antiseptics were used two or more times per day in 94.7% of respondents.Discussion: Halodine for oral and nasal decontamination appears to be well tolerated for repeated daily use, even in individuals reporting 4 months or more of use. No individuals reported severe symptoms such as loss of taste, loss of smell, or dizziness. No pain was reported in 99.2% of individuals,while the remaining &lt;1% reported very mild/minimal discomfort. Conclusion: These findings point to high tolerability of Halodine for repeated oral and nasal decontamination.

Eradication of Staphylococcus aureus Post-Sternotomy Mediastinitis Following the Implementation of Universal Preoperative Nasal Decontamination With Mupirocin: An Interrupted Time-Series Analysis.

Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990-2003) and postintervention (2005-2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P < .0001). Interrupted time-series analysis demonstrated a statistically significant annual reduction in S. aureus PSM of -9.85 cases per 1000 sternotomies (-13.17 to -6.5; P < .0001) in 2005, with a decreasing trend maintained over the following 5 years and an estimated relative reduction of 84.8% (95% confidence interval [CI], 89.25-74.09%). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio, 3.7; 95% CI, 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre- or postintervention periods. Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

RHINITIS MEDICAMENTOSA: ПРИНЦИПИ ДІАГНОСТИКИ ТА ЛІКУВАННЯ

RHINITIS MEDICAMENTOSA: PRINCIPLES OF DIAGNOSIS AND TREATMENT Ye. Bogomolov1, S. V. Zaikov2, S. O. Zubchenko3 1 National Pirogov memorial medical university, Vinnitsya, Ukraine 2 Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine 3 Danylo Halytsky Lviv National Medical University, Lviv, Ukraine Abstract. Nasal congestion is a common symptom that affects up to 30 % of the world’s population. Uncontrolled intake of nasal decongestants to relieve nasal congestion leads to rhinitis medicamentosa (RM), a subtype of drug-induced rhinitis, which is a chronic dysfunction of the nasal mucosa due to prolonged use of local vasoconstrictors. RM occurs with equal frequency in men and women, but is more common in young and middle-aged adults, and the described incidence into laryngological clinics ranges from 1 % to 7 %. In Ukraine, the problem is not statistically studied, but almost 2 billion hryvnias were spent by Ukrainians on the purchase of 40 million packages of decongestants per year (August 2019 — July 2020), which means that every Ukrainian, including newborns, used at least 1 package of this drug. The main diagnostic criteria for RM, in addition to detecting the presence of nasal obstruction (hyperemia, edema of the nasal mucosa with disorders of nasal breathing and nasal congestion) and reduction of edema of the nasal mucosa with the use of vasoconstrictors, are indications of a history of long-term nasal decontamination. The only drugs whose efficacy in RM has been proven not only in experimental but also in clinical randomized placebo-controlled studies are intranasal glucocorticoids (GCS). Currently, intranasal GCS are considered the most effective drugs available for the treatment of RM. Key words: rhinitis medicamentosa, nasal congestion, nasal decongestants.

Efficacy of universal preoperative decolonization with Polyhexanide in primary joint arthroplasty on surgical site infections. A multicenter before-and after-study

BackgroundSurgical site infections (SSI) are rare but severe complications after total joint arthroplasty (TJA). Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of SSI with Staphylococcus aureus (S. aureus).ObjectiveTo determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA.MethodsPatients scheduled for elective hip or knee TJA in 5 participating certified orthopedic centers were included between 2015 and 2018 into this before and after study. Data on patients, surgeries and infections were prospectively collected. CDC-criteria were used to define and categorize Infections within 90 days after surgery. From January 2017 on, patients received decolonization sets containing Polyhexanide. Patients performed a 5 day decolonization regimen starting 4 days prior to surgery which included wipes, nasal decontamination and oral solution.ResultsThirteen thousand, three hundred fifteen patients received TJA. During intervention 4437 decolonization sets were distributed among 7175 patients.Overall SSI rates increased from 0.68 /100 surgeries to 0.91/ 100 surgeries after implementation of the intervention (IRR 1.32; 95% CI 0.90–1.96). Time series analysis identified an increasing trend of SSI prior to the intervention. After implementation overall SSI rates plateaued. Regression analysis revealed surgery during intervention period to be an independent risk factor for developing a SSI (OR 1.34; 95%CI 1.18–1.53).Initial SSI rates due to S. aureus were 0.24/100 surgeries and decreased to 0.14/100 surgeries (IRR 0.57; 95% CI 0.25–1.22) after introduction of decolonization. Regression analysis revealed surgery during intervention period to be an independent protective factor for developing a SSI with S. aureus (OR 0.57, 95% CI: 0.33–0.99).Overall deep S. aureus SSI decreased significantly from 0.22/100 surgeries to 0.00/100 surgeries in patients adherent to protocol (IRR 0.00, 95% CI 0.00–.85).ConclusionUniversal decolonization with Polyhexanide did not reduce overall surgical site infections, but was effective in reducing Staphylococcus aureus - surgical site infections following elective joint arthroplasty. Polyhexanide could extend the list of alternatives to already established decolonization strategies.Trial registrationThe trial was registered at the German Registry for clinical studies www.drks.de (DRKS00011505).

Efficacy of Povidone-Iodine Nasal and Oral Antiseptic Preparations Against Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2).

Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the global pandemic of coronavirus disease 2019 (COVID-19). From the first reported cases in December 2019, the virus has spread to over 4 million people worldwide. Human-to-human transmission occurs mainly through the aerosolization of respiratory droplets. Transmission also occurs through contact with contaminated surfaces and other fomites. Improved antisepsis of human and nonhuman surfaces has been identified as a key feature of transmission reduction. There are no previous studies of povidone iodine (PVP-I) against SARS-CoV-2. This study evaluated nasal and oral antiseptic formulations of PVP-I for virucidal activity against SARS-CoV-2. This is the first report on the efficacy of PVP-I against the virus that causes COVID-19. Povidone iodine nasal antiseptic formulations and PVP-I oral rinse antiseptic formulations from 1% to 5% concentrations as well as controls were studied for virucidal efficacy against the SARS-CoV-2. Test compounds were evaluated for ability to inactivate SARS-CoV-2 as measured in a virucidal assay. SARS-CoV-2 was exposed directly to the test compound for 60 seconds, compounds were then neutralized, and surviving virus was quantified. All concentrations of nasal antiseptics and oral rinse antiseptics evaluated completely inactivated the SARS-CoV-2. Nasal and oral PVP-I antiseptic solutions are effective at inactivating the SARS-CoV-2 at a variety of concentrations after 60-second exposure times. The formulations tested may help to reduce the transmission of SARS-CoV-2 if used for nasal decontamination, oral decontamination, or surface decontamination in known or suspected cases of COVID-19.

Nasal decolonization of Staphylococcus aureus and the risk of surgical site infection after surgery: a meta-analysis

AimTo assess the effects of nasal decontamination on preventing surgical site infections (SSIs) in people who are Staphylococcus aureus carriers undergoing different types of surgeries and diverse measures of decolonization.MethodsRelevant randomized controlled trials (RCTs) were identified through systematic searches of the PubMed, Embase, Web of science, and the Cochrane Library databases. The risk ratios (RRs) and 95% confidence intervals (CIs) were calculated and the effects model was chosen according to the heterogeneity. Subgroup analyses were performed according to different types of surgeries and measures of decolonization that Staphylococcus aureus carriers were applied.ResultsTwenty RCTs published between 1996 and 2019 involving 10,526 patients were included. Pooled results showed that the overall SSIs and pulmonary surgery SSIs presented with a statistical difference in measures of nasal decontamination (RR = 0.59 and 0.47, respectively, both p < 0.01). However, the associations between nasal decolonization and increased risks of SSIs in orthopedics surgery or cardiovascular surgery remained insignificant in studies. As for the diverse measures of nasal decontamination, 50% used mupirocin, 15% used chlorhexidine, 30% used different types of antimicrobial drugs, and 5% use others. The SSIs rate were decreased after chlorhexidine (RR = 0.474, 95% CI 0.259–0.864), while no significant difference was shown in the use of mupirocin (RR = 0.871, 95% CI 0.544–1.394).ConclusionIt seems that nasal decolonization of Staphylococcus aureus may be associated with a reduction of SSIs in these patients, especially in patients who have been administered by pulmonary surgeries or treated with chlorhexidine.

Impact of skin and nasal decontamination before cardiac surgery on postoperative Staphylococcus infection rate in children

BackgroundPostoperative infections occur in about 10% of pediatric cardiac surgeries, involving Staphylococcus aureus in most of the cases. Nasal decontamination of Staphylococcus aureus with mupirocin has been reported to reduce postoperative Staphylococcus aureus infections after cardiac surgery in adults, but the effect of preoperative decontamination in children undergoing cardiac surgery has not been enough studied to determine a consensus. AimsWe tried to evaluate the impact of systematic preoperative decolonization with intra nasal mupirocin application and chlorhexidine soap skin washing, on postoperative Staphylococcus infection in children undergoing cardiac surgery. MethodsWe conducted a monocentric retrospective study including children from 7days-old to 18 years-old undergoing cardiac surgery. Our population was divided in three groups according to decolonization protocol (groupN: no decolonization, group T: targeted decolonization in Staphylococcus aureus carriers only, and group S: systematic decolonization). ResultsThree hundred and ninety three children were included between October 2011 and August 2015(122 in group N, 148 in group T and 123 in group S). Staphylococcus infection rate significantly decreased in group S compared to group N (0.8% vs. 7.7%; P<0.05) and tended to decrease in group S compared to group T (0.8% vs. 4.7%; P=0.06). Systematic decontamination also significantly reduced the rate of infections starting from the skin (including surgical site infections and bloodstream infections), but had no effect on the rate of pulmonary infections. The lack of decontamination was associated with a higher risk of postoperative Staphylococcus infection (15% vs. 41%, P<0.05). ConclusionOur study suggests that systematic preoperative skin and nasal decontamination decrease postoperative SI in children undergoing cardiac surgery.

Enhanced topical delivery of non-complexed molecular iodine for Methicillin-resistant Staphylococcus aureus decolonization

Staphylococcus aureus, a leading cause of serious human infections in both healthcare and community settings, is increasingly difficult to control due to expanding resistance to multiple antibiotic classes. Methicillin-resistant S. aureus (MRSA) strains have disseminated on a global scale and are associated with adverse patient outcomes, increased hospital stays, and significant economic costs to the healthcare system. A proximal step in S. aureus infection is colonization of the nasal mucosa, and effective strategies to decolonize high risk patients to reduce the risk of invasive infection and nosocomial spread represent an important clinical priority. With rising resistance to mupirocin, the most common antibiotic utilized for nasal MRSA decontamination, we are examining the use of pure molecular iodine (I2)-based formulations for this indication. Recently, an iodophor formulation of povidone-iodine (PVP-I) has shown significant promise for nasal MRSA decontamination by swabbing the anterior nares of patients in hospital settings, but the I2 concentration in this treatment is less than 0.01% of total iodine species present and like all providone-iodine formulations causes skin staining. Here we determine that a novel non-staining formulation of I2 combined with the safe organic emollient glycerin delivers high local concentrations of the active antimicrobial entity (I2) with minimal evaporative loss, exhibits activity at ∼1 part per million against MRSA and other important Gram-positive and -negative human pathogens. This formulation for I2 topical delivery produced similar reductions in mean bacterial burden and was associated with fewer treatment failures (<2-logfold reduction) than PVP-I in a murine model of MRSA nasal decontamination. Formulations of I2 in glycerin emollient merit further exploration as topical disinfectants for human medical indications.

Does Staphylococcus aureus nasal decontamination affect the rate of early surgical site infection in adolescent idiopathic scoliosis surgery?

Surgical site infection (SSI) is a main complication after adolescent idiopathic scoliosis (AIS) surgery. Nasal colonization with S. aureus is a known risk factor for developing nosocomial infections in cardiac surgery. However, the risk in orthopedic surgery remains unclear, especially in spine surgery. This study aims to report the efficacy of a preoperative nasal decontamination program in S. aureus carriers on the incidence of early SSI after AIS posterior surgery. Between January 2014 and July 2017, all AIS patients were screened preoperatively with nasal swabs and decontaminated if positive 5days before surgery. Early SSI was identified, and microorganisms findings were analyzed within nasal carriage and compared to a previous series published before the decontamination program (2007-2011). Among the 331 AIS posterior fusion performed during the study period, incidence of positive nasal swab was 23% (n = 75). Those were preoperatively decontaminated. In comparison with the period before the nasal decontamination program, incidence of S. aureus early SSI significantly decreased from 5.1 to 1.3%, p < 0.05. None of those S. aureus decontaminated patients had an early S. aureus SSI. In all cases of S. aureus infections, S. aureus nasal screening was negative with a mean delay of 315days (± 115) before surgery, which was significantly different from the global cohort (104days ± 67, p < 0.05). Preoperative S. aureus nasal decontamination was associated with a significant decrease in S. aureus SSI. Optimal delay of nasal screening needs to be optimized in order to diagnose intermittent S. aureus carriers. These slides can be retrieved under Electronic Supplementary Material.

Dekolonisation bei Nachweis von Methicillin-sensiblen Staphylococcus aureus bei Mitarbeitern einer neonatologischen Intensivstation

In 2016, an increased rate of methicillin-susceptible Staphylococcus aureus colonization was detected on a neonatal intensive care unit at the Leipzig University Hospital. Typing results showed a predominant spa-type t091. Considering nosocomial clustering, several infection prevention measures (e. g. intensified standard precautions, single-occupancy room, cohorted patients, continuing education of staff) were introduced, including staff screening followed by decolonization of colonized health care workers. Staff members showing positive on screening carried out a 5-day decolonization program at home. Decolonization products containing octenidine as active ingredient were used first. At the earliest, 48 h after completing the procedure, the success of the intervention was tested (3 buccal and nasal swabs were taken on consecutive days). If 2 attempts at decolonization were not successful, staff members were provided with a mupirocin-containing nasal ointment instead of octenidine. Of 128 employees examined, 43 (33.6%) were identified as carriers of S. aureus. In 9 cases (20.9%; 9/43) the S. aureus matched with type t091. 2 carriers (4.7%; 2/43) of MRSA were detected as well. The first decolonization attempt against t091 and MRSA failed altogether. After a second decolonization, 3 cases became negative. Finally, 8 remaining staff members were decolonized successfully with mupirocin containing nasal ointment. Various reasons might explain the difficulties of decolonization such as the challenge of managing decolonization at home, inhibitory factors as well as inconsistent performance of decolonization measures. Additionally, differences between the preparations for the nasal decontamination may be considered.

Post-sternotomy mediastinitis in the modern era.

Post-sternotomy mediastinitis is associated with significant mortality and morbidity. Despite surgical advances in cardiac surgery and improvements in perioperative care, mediastinitis remains a devastating post-operative complication. This study provides a comprehension review of post-sternotomy mediastinitis in the modern era, and discusses the incidence, risk factors, microbiology, prevention, and management of this complication. This review was based on a PubMed/MEDLINE literature search up until 9th March 2017 for publications relevant to mediastinitis post-cardiac surgery. The incidence of mediastinitis post-cardiac surgery varies between 0.3 and 3.4%, and is associated with an in-hospital mortality ranging from from 1.1 to 19%. The risk of developing post-operative mediastinitis is dependent on the patients' co-morbidities (diabetes, obesity, smoking, renal failure) and surgical techniques (bilateral pedicled internal mammary harvest, excessive cautery, long duration of surgery). Preventative measures including skin and nasal decontamination, antibiotic prophylaxis, strict glycemic control, and meticulous surgical techniques are crucial in reducing the risk. Treatment of post-operative mediastinitis include culture-directed antibiotic therapy, early wound exploration, and debridement followed by sternal reconstruction/closure. Vacuum-assisted therapy can be used as a single line therapy or as a bridge to eventual sternal reconstruction/closure. Post-sternotomy mediastinitis remains a potentially fatal complication of cardiac surgery despite the advancements in the perioperative care in the modern era. Management on preventative measures, prompt diagnosis, and managements are crucial in reducing associated mortality and morbidity.

Nasal decontamination for the prevention of surgical site infection in Staphylococcus aureus carriers.

Surgical site infection rates in the month following surgery vary from 1% to 5%. Due to the large number of surgical procedures conducted annually, the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Nasal decontamination using antibiotics or antiseptics is performed to reduce the risk of SSIs by preventing organisms from the nasal cavity being transferred to the skin where a surgical incision will be made. Staphylococcus aureus (S aureus) colonises the nasal cavity and skin of carriers and can cause infection in open or unhealed surgical wounds. S aureus is the leading nosocomial (hospital-acquired) pathogen in hospitals worldwide. The potential effectiveness of nasal decontamination of S aureus is thought to be dependent on both the antibiotic/antiseptic used and the dose of application; however, it is unclear whether nasal decontamination actually reduces postoperative wound infection in S aureus carriers. To assess the effects of nasal decontamination on preventing surgical site infections (SSIs) in people who are S aureus carriers undergoing surgery. In September 2016 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched three clinical trial registries and the references of included studies and relevant systematic reviews. There were no restrictions based on language, date of publication or study setting. Randomised controlled trials (RCTs) which enrolled S aureus carriers with any type of surgery and assessed the use of nasal decontamination with antiseptic/antibiotic properties were included in the review. Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment. We located two studies (291 participants) for inclusion in this review. The trials were clinically heterogeneous with differences in duration of follow-up, and nasal decontamination regimens. One study compared mupirocin (2% contained in a base of polyethylene glycol 400 and polyethylene glycol 3350) with a placebo in elective cardiac surgery patients; and one study compared Anerdian (iodine 0.45% to 0.57% (W/V), chlorhexidine acetate 0.09% to 0.11% (W/V)) with no treatment also in cardiac surgery patients. The trials reported limited outcome data on SSI, adverse events and secondary outcomes (e.g. S aureus SSI, mortality). Mupirocin compared with placeboThis study found no clear difference in SSI risk following use of mupirocin compared with placebo (1 trial, 257 participants); risk ratio (RR) 1.60, 95% confidence interval (CI) 0.79 to 3.25 based on 18/130 events in the mupirocin group and 11/127 in the control group; low-certainty evidence (downgraded twice due to imprecision). Anerdian compared with no treatmentIt is uncertain whether there is a difference in SSI risk following treatment with Anerdian compared with no treatment (1 trial, 34 participants); RR 0.89, 95% CI 0.06 to 13.08 based on 1/18 events in the Anerdian group and 1/16 in the control group; very low certainty evidence (downgraded twice due to imprecision and once due to risk of bias). There is currently limited rigorous RCT evidence available regarding the clinical effectiveness of nasal decontamination in the prevention of SSI. This limitation is specific to the focused question our review addresses, looking at nasal decontamination as a single intervention in participants undergoing surgery who are known S aureus carriers. We were only able to identify two studies that met the inclusion criteria for this review and one of these was very small and poorly reported. The potential benefits and harms of using decontamination for the prevention of SSI in this group of people remain uncertain.

1025Impact of Nasal Decontamination with Nasal Iodine as part of a Preoperative Surgical Site Infection (SSI) Prevention Bundle in Orthopedic Implant Surgeries

Nasal iodine as a bundled approach can be a rapid and effective method for prevention of all Surgical Site Infections (SSIs) and also S. aureus SSIs in orthopedic implant surgeries by decontamination of the nares. The individual effect of nasal iodine in reduction of SSI in orthopedic surgeries will need to be determined in future studies, but this offers an alternative to screening and decolonization with mupirocin. Conclusion  Staphylococcus aureus is the leading cause of surgical site infections. 80 percent of S. aureus infections are caused by the patients own nasal flora. Nasal iodine (3MTM Skin and Nasal Antiseptic ) is effective for 1 to 12 hours post application and can be used for decolonization (reduces organism burden by 99.5% in the nares) Nasal iodine application is quick and generally done as a single application just prior to surgery. Background This study was conducted at Detroit Receiving hospital starting March, 2013.  This approach was used as part of a bundle which included perioperative CHG bathing and addition of vancomycin prophylaxis.  Infection rates for knee and hip surgeries were collected by infection control personnel during routine surveillance for surgical site infections. Infection rates were compared 1 year before and 1 year after intervention. Methods Results Background: Nasal carriage of Staphylococcus aureus (SA) has been shown to be an independent risk factor for SA surgical site infections (SSI), with a SSI rate 2-9 times higher in carriers. Decolonization with nasal mupirocin is often recommended for carriers or high risk individuals, however this process requires preoperative screening and patient compliance with application days prior to surgery. Nasal decontamination with nasal iodine just prior to surgery offers a rapid method of decreasing the nasal burden of SA in high risk joint implant surgeries. Methods: Nasal decontamination with nasal iodine (3MTM Skin and Nasal Antiseptic) of all patients undergoing hip and knee prosthetic joint replacement was implemented pre-operatively since March 2013 at Detroit Receiving Hospital. This intervention was coupled with reinforcement of perioperative CHG bathing and the addition of vancomycin to routine Blactam prophylaxis. Hip arthroplasty (HPRO) and knee arthroplasty (KPRO) infection rates were reviewed for 1 year before and after intervention. Results: There was a 43.25% reduction in HPRO and KPRO infections during this time period. A decrease in the average rate from 2.59 to 1.45 infections per 100 procedures (OR-0.56, p=0.24) was seen. SA infection were reduced from an average rate of 1.29 to 0.63 infections per 100 procedures (OR – 0.48, p=0.30). This resulted in a reduction of 5 infections and an approximate net cost saving of $142,409. Conclusions: Nasal decontamination with iodine offers an alternative to nasal decolonization with mupirocin in the prevention of orthopedic implant infections and was effective as part of a perioperative SSI prevention bundle.  A decrease in the average rate from 2.59 to 1.45 infections per 100 procedures (OR-0.56, p=0.24) was seen. {Rate of HPRO decreased from 2.1 to 1.86 infections per 100 procedures (OR-0.87, p=0.84) and rate of KPRO decreased from 3.07 to 1.12 infections per 100 procedures (OR0.36, p=0.14)}  SA infection were reduced from an average rate of 1.29 to 0.63 infections per 100 procedures (OR – 0.48, p=0.30).  This resulted in a reduction of 5 infections and an approximate net cost saving of $142,409. Surgical site Combined Hip and Knee prosthesis infections / # procedures by OR month x 100

Preventing Deep Infection in Total Knee Replacement

BACKGROUND: The rate of infection following primary total knee replacement (TKR) ranges between 1 and 2%. The medical community has implemented many practices with the intention of preventing infection after TKR. QUESTION: What are the prevention measures to reduce infection risk after TKR? METHODS: A PubMed (MEDLINE) search and a Cochrane Library search were performed until 31 March 2014. Six hundred and fifty-seven articles were found but only 42 were finally analysed. The main criteria for selection were that the articles addressed the aforementioned question. RESULTS: Rheumatoid arthritis, diabetes mellitus, immunosuppression treatment, psoriasis, and previous infections in the knee are the risk factors most clearly related with TKR infection. Appropriate patient selection is fundamental. Staphylococcus Aureus is the most common organism in infected TKRs. Systematic preoperative screening by swab is very important. Prevention of MRSA-positive cases by means of nasal decontamination (mupirocin 3 days) is advisable. Preoperative antibiotic prophylaxis has shown to be an efficient method to lower infection rates. Appropriate surgeon´s preparation and clean air in the operating room (OR) also seem to be important. Many authors have used ORs equipped with laminar air flow (LAF) although some authors have recently found that the incidence of infection decreased after abandoning the LAF in ORs. Adequate skin preparation and dressings also appear to be very important. Prolonged operative time seems to correlate with increased infection rate after TKR. The correlation between antibiotic-loaded cement and the risk of infection is still controversial. CONCLUSIONS: Prevention measures could help diminish the infection rate in patients undergoing TKR but the efficacy of some preventive practices is still controversial.

Preventing surgical site infection in haemophilia patients undergoing total knee arthroplasty

The rate of infection following primary total knee arthroplasty (TKA) in the general population is 1% on average. However, in persons with haemophilia (PWH), the mean rate of infection following primary TKA is nearly 8%. why is the infection rate higher in persons with haemophilia compared with the general population? what should be done to correct this? A PubMed (MEDLINE) search and a Cochrane Library search were performed. The most important articles as judged by the author were selected for this review. The main criteria for selection were that the articles addressed the prevention of infection in PWH undergoing TKA. Patient-related risk factors predisposing to postoperative infection in the general population include immunodepression and previous infection in the knee. Methicillin-resistant Staphylococcus aureus (MRSA) is the most common organism in infected TKAs. Systematic preoperative screening by swab is very important. Prevention of MRSA-positive cases by means of nasal decontamination (mupirocin 3 days) is advisable. Preoperative antibiotic prophylaxis has shown itself to be an efficient method to lower infection rates. Operating theatres ideally should be equipped with laminar flow. In PWH, there are three additional risk factors: insufficient haemostasis, HIV-positive status, and central venous catheters (CVCs). Implementing the preventive measures for the general population and a sufficient level of clotting factor for 2-3 weeks can help diminish the infection in PWH undergoing TKA. In HIV-positive patients with CD4 count less than 200 cells/μl , early, vigorous treatment should be instituted for suspected infection and surgical intervention individualized based on the balance of risks and benefits. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Caregiver education is an integral part of CVC use and the procedural practices of users should be regularly reassessed. If TKA is contraindicated, arthroscopic knee joint debridement can relieve pain for several years and delay the need for TKA.

Carriage frequency, phenotypic and genotypic characteristics of Staphylococcus aureus isolated from dialysis and kidney tranplant patients at a hosptial in northern paraná.

The objective of the present study was to determine the frequency of Staphylococcus aureus nasal carriage among dialysis and kidney transplant patients, to identify the antimicrobial resistance profile of these strains and to verify their genetic profiles with the RW3A primer. The study included 159 individuals, comprising 111 dialysis and 48 kidney transplant patients. Of the 48 transplant patients, 75% were positive for S. aureus, whereas 49% of the 111 dialysis patients were carriers. Two samples yielded conflicting results for oxacillin sensitivity between the disk diffusion and minimum inhibitory concentration (MIC) assays: both were sensitive by the disk diffusion assay and resistant by MIC (4 μg/ml). In the antibiogram by disk diffusion, ten samples were resistant to cefoxitin, among which eight were also resistant to oxacillin. The resistance of the ten samples to cefoxitin by the disk diffusion assay was confirmed by MIC. Of the ten oxacillin-resistant samples, eight harbored the mecA gene. All samples were sensitive to vancomycin, and most were resistant to penicillin and demonstrated high rates of resistance to the other antimicrobials tested. The samples from dialysis patients exhibited a more homogenous genetic profile. Among the samples with a high percent similarity, no correlation with sensitivity or resistance to oxacillin was observed. According to the results of this study, the implementation of prevention and control measures, such as increased restrictions on prescriptions for antimicrobial drugs and nasal decontamination prior to high-risk procedures, is recommended.