Preoperative Methicillin-resistant Staphylococcus Aureus Screening Research Articles

IMPACT OF ACTIVE SURVEILLANCE SCREENING OF MRSA ON SURGICAL SITE INFECTION RATES- A PROSPECTIVE INTERVENTIONAL STUDY

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common cause of surgical site infections. Different methods are employed to reduce nosocomial spread including application of Isolation precautions, admission screening cultures and MRSA decolonization 3,4,5,6,7. Preoperative MRSA screening in patients undergoing cardiac surgeries can reduce the risk of surgical site infections. To evaluate the significance of preoperative MRSA screening on rates of surgical site infections in cardiac surgery patients Material and Methods: This was a prospective interventional study, conducted at the National Institute of Cardiovascular diseases, Karachi from 1st February 2022- 31st July 2022. Preoperative MRSA screening in patients undergoing cardiac surgeries was performed at the Microbiology Laboratory. Patients identified as colonized were isolated and decolonized with chlorhexidine baths prior to surgeries. Surgical site infections (SSIs) rates were recorded by Infection control nurse through active surveillance for the screening period. SSI rates for a prescreening period of 6 months (August 2021- January 2022) was retrieved through electronic medical records for comparison. Results: Total 359 patients were screened from 1st February 2022- 31st July 2022, out of which 20 were colonized with MRSA. None of the patients who screened positive for MRSA developed SSI. 11 SSIs with MRSA were reported from August 2021- January 2022 and 4 SSIs were reported from February 2022-July 2022 (p value < 0.05). Conclusion: It can be concluded that active MRSA screening and subsequent implementation of decolonization policy would decrease the percentage of SSI in cardiac surgery Keywords: MRSA, Screening, Surgical site infection, Surveillance

234. Does nasal screening for methicillin resistant Staphylococcus aureus (MRSA) prevent deep surgical site infections for elective cervical spinal fusion?

<h3>BACKGROUND CONTEXT</h3> Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. <h3>PURPOSE</h3> The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting <h3>OUTCOME MEASURES</h3> Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. <h3>METHODS</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. <h3>RESULTS</h3> This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. <h3>CONCLUSIONS</h3> There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Attitudes and Awareness of Cornea Specialists and Oculoplastic Surgeons toward Methicillin-Resistant Staphylococcus aureus Decolonization.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) decolonization is widely utilized in many medical subspecialities to reduce surgical site infections, but routine ophthalmic implementation has been limited. The aim of this study was to investigate the attitudes and actual practice of corneal specialists and oculoplastic surgeons toward MRSA decolonization as a preventive measure in ophthalmic surgery. Materials and Methods: A web-based survey was sent to cornea specialists and oculoplastic surgeons to assess their knowledge, beliefs, and practices regarding MRSA prophylaxis and the use of MRSA decolonization to prevent post-operative infections. Results: A total of 180 surgeons participated in this study: 71% of respondents agreed that MRSA colonization plays a role in post-operative infection of the eye and adnexal structures; 65% stated that MRSA decolonization could help prevent MRSA infection. Although 41% of respondents would change their management in response to a positive pre-operative MRSA screening result, only 18% performed pre-operative screening. Seventeen percent of respondents indicated that they offer pre-operative decolonization for MRSA-positive patients; the most frequently applied technique was the use of nasal antibiotic agents such as mupirocin, followed by antiseptic baths. Peri-operative MRSA prophylaxis was used by 18% of respondents; pre-operative MRSA decolonization was used in conjunction by 8.5 % of respondents. Conclusions: Although MRSA decolonization has been validated in fields outside of ophthalmology, there has not been widespread adoption of this practice among oculoplastic surgeons and cornea specialists. Prospective MRSA decolonization ophthalmic studies are necessary if evidence-based management guidelines are to be developed.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

Retrospective cohort study. The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

P143. Impact of preoperative MRSA screening on infection risk in spine patients

<h3>BACKGROUND CONTEXT</h3> Postoperative infection in the setting of spine surgery remains a significant concern for patients, surgeons, and health care institutions due to the associated morbidity, mortality, and societal costs. Prior studies have shown methicillin resistant staphylococcus aureus (MRSA) infection comprises a sizable portion of those infections. Given this information, the authors conducted a quality improvement protocol to screen and prophylactically treat elective spinal surgery patients colonized with MRSA. This study evaluates the changes in outcomes before and after the initiation of the protocol. <h3>PURPOSE</h3> The goal of this study is to compare the rates of infection before and after the implementation of a preoperative MRSA screening and treatment protocol for spine patients undergoing laminectomy or fusion. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort review. <h3>PATIENT SAMPLE</h3> A total of 26,614 spinal fusion and laminectomy cases were included, of which there were 72 MRSA infections. <h3>OUTCOME MEASURES</h3> Incidence and relative risk of surgical infection. <h3>METHODS</h3> A retrospective cohort analysis was conducted on patients who underwent spinal fusion and laminectomy before and after the implementation of the MRSA screening and treatment protocol. The relative risk of MRSA and methicillin sensitive staphylococcus aureus (MSSA) infection before and after screening was calculated. Additionally, multivariate analysis was used to assess demographic characteristics as potential independent predictors of infection. <h3>RESULTS</h3> The relative risk of all infections, including both MRSA and MSSA, was significantly lower post protocol than before its implementation (p < 0.001 for both). Patients with infection were significantly younger, had a shorter length of procedure, higher ASA class, and more likely to be diabetic (p < 0.001 for all). Multivariate logistic regression showed that age, length of procedure, and ASA class were independent predictors of infection. <h3>CONCLUSIONS</h3> The implemented quality improvement protocol demonstrated that prophylactically treating patients colonized MRSA infection preoperatively helped reduced the rate of infection, including both MRSA and MSSA infections, after spine surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Can preoperative screening for methicillin-resistant staphylococcus aureus effectively predict surgical site infections in spine surgeries?

Introduction: Hospital care-associated infections prolong hospital stay and thus increased financial burden, causes long-term disability and mortality in patients and can increase resistance of microorganisms to antimicrobials. Surgical site infections (SSIs) are the most frequent type of hospital care-associated infections in the developing countries. Staphylococcus is the most commonly isolated organism with methicillin-resistant Staphylococcus aureus (MRSA) posing a great threat. The most common human reservoir for S. aureus is the nares. We propose a study to evaluate the efficacy of preoperative screening of MRSA by nasal and throat culture by correlating it with postoperative SSI. Study Design: Prospective study. Purpose of the Study: 1. To determine the prevalence of MRSA colonization in a population of patients scheduled for elective spine surgery. 2. To determine whether preoperative nasal and throat swab cultures for MRSA are predictive of postoperative SSI in patients undergoing spine surgery. Materials and Methods: Two hundred and forty-eight patients who underwent spine surgery at Baby Memorial Hospital, Calicut, from December 2018 onward are included in this study. Patients who had spine surgeries for infections were excluded from the study. Patients who developed postoperative SSIs were cross-checked with preoperative data and analyzed whether the infecting organism is same as in the preoperative nasal and throat swab culture (if it is present). The significance of the correlation between preoperative nasal and throat swab culture and postoperative SSI are assessed statistically with Chi-square test. Discussion: Among the 248 patients in this study, preoperative nasal and throat swab culture yielded MRSA in 27 patients (nasal – 24, throat – 2, and both – 1). Out of 248 patients, 6 patients developed SSIs with MRSA, but none of them had MRSA in preoperative nasal or throat swab culture. Conclusion: Preoperative MRSA screening by throat and nasal swab is not routinely needed in spine surgery as it appears to carry no positive predictive value in postoperative SSIs.

Risk Factors and Prevention of Surgical Site Infections Following Spinal Procedures.

Study Design:Focused literature review.Objective:The objective of this article was to help identify potential risk factors as well as strategies to help prevent surgical site infections (SSIs) in spine surgery.Methods:An article search was performed using PubMed, EMBASE, and the Cochrane database of systematic reviews using the terms “surgery” OR “surgical” AND “spine” OR “spinal” AND “infection”. Systematic review articles, meta-analyses, and clinical trials with more than 100 patients were reviewed.Results:Both patient and perioperative factors contribute to the development of SSIs. Patient factors such as smoking, obesity, diabetes, Methicillin-resistant Staphylococcus aureus (MRSA) colonization, and malnutrition are all modifiable risk factors that can lead to SSIs. Procedural steps, including preoperative MRSA screening and treatment for colonization, preoperative antibiotics, skin preparation, minimizing operative time, antibiotic or betadine irrigation, avoiding personnel turnover, and postoperative wound care have also been shown to decrease infection rates.Conclusion:There are several measures a spine practitioner may be able to take in the preoperative, intraoperative, and postoperative settings. Protocols to counsel patients regarding modification of preexisting risk factors and ensure adequate antimicrobial therapy in the perioperative period may be developed to reduce SSIs in spine surgery.

Addition of Vancomycin to Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint Arthroplasty.

With increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in patients undergoing hip and knee arthroplasty, some have advocated a dual-antibiotic regimen including vancomycin as prophylaxis against surgical site infections. However, routine administration of vancomycin may result in impaired renal functions in susceptible patients. The purpose of this study was to determine whether patients receiving antibiotic prophylaxis with cefazolin and vancomycin have a higher risk of postoperative acute kidney injury (AKI) compared with patients receiving cefazolin alone before elective primary hip and knee arthroplasty. We also aimed to compare severity and recovery of AKI in these two cohorts and to determine independent risk factors for AKI. We retrospectively evaluated a series of 1828 patients undergoing primary hip and knee arthroplasty over a 2-year period who received either cefazolin (n = 500) or cefazolin and vancomycin (n = 1328) as perioperative antibiotic prophylaxis. During the study period, a perceived high prevalence of MRSA infections at our institution led some surgeons to add vancomycin to the prophylactic antibiotic regimen. The patient characteristics, case mix, and preoperative renal function and baseline creatinine clearance were similar between the two groups. We defined AKI according to the published Acute Kidney Injury Network (AKIN) criteria, and the risk of AKI in both groups was compared. We also compared the proportions of patients by AKIN severity stage and assessed recovery as defined by creatinine levels showing kidney function reaching 50% baseline. The American Society of Anesthesiologists (ASA) classification, preoperative chronic kidney disease, intraoperative fluid requirements, and estimated blood loss were recorded. We analyzed the data using a multivariate logistic regression model to identify potential independent risk factors, including dual antibiotic therapy. Patients receiving dual antibiotics were more likely to develop AKI compared with those receiving cefazolin alone (13% versus 8%, p = 0.002). Dual-antibiotic prophylaxis also was associated with greater severity; patients in the dual antibiotic group had higher rates of Grade II and III acute kidney injury (3% versus 0%, p = 0.003). There was no difference in the rate of return to baseline renal function (2 ± 1.4 days versus 3 ± 3.4 days; mean difference, 0.5 days; 95% confidence interval [CI], -0.2 to 1.2 days; p = 0.155). Controlling for confounding variables, dual antibiotic prophylaxis (adjusted odds ratio [OR], 1.82; 95% CI, 1.25-2.64; p = 0.002), ASA class (adjusted OR, 1.64; 95% CI, 1.24-2.17; p = 0.001), and preoperative kidney disease (adjusted OR, 1.81; 95% CI, 1.30-2.52; p = 0.001) were independent risk factors for AKI after primary total joint arthroplasty. Without a clear advantage in reducing surgical site infections, the utility and safety of routine addition of vancomycin to the prophylactic regimen in all patients undergoing primary hip and knee arthroplasty should be avoided. Further prospective studies should look at the efficacy of preoperative MRSA screening, decolonization, and selective use of vancomycin in high-risk patients. Level III, therapeutic study.

MRSA screening in ambulatory upper limb trauma day cases

Aims: Approximately 3% of the UK population are carriers for methicillin-resistant Staphylococcus aureus (MRSA). The NHS set a target of reducing MRSA nosocomial infections by 20% in 2012/13. The Department of Health instigated mandatory universal screening for elective and trauma surgery at significant cost and increased resource demand. Patients presenting to our service with simple upper limb trauma requiring day case surgical intervention are included in mandatory universal MRSA screening, despite being discharged post-operatively before any screening result is known. The aim of this study was to examine the effectiveness of mandatory screening in our patient cohort. Methods: We undertook a retrospective audit of 500 consecutive day case upper limb trauma cases that were managed in our hand unit between 1 May and 31 October 2011. Patient demographics, injury, operative intervention, pre-operative MRSA screening result and post-operative wound swab results were examined. Patients with frankly infective conditions such as abscesses and flexor tenosynovitis were excluded. Results: 78% of our patients were male. 91% were less than 60 years old. 98% of patients had a pre-operative MRSA screening swab. None were positive. 2% had positive post-operative swabs for organisms other than MRSA. Conclusion: We approached our trust and successfully proposed that young, ambulatory, day-case upper limb trauma patients be exempt from mandatory screening. At an average throughput of 1000 cases per annum and an estimated cost of £42.50 per MRSA screen, excluding this cohort of patients from mandatory screening has saved approximately £42 500. The true savings would be likely far greater if applied to similar cohorts across the trust, bringing with it a reduction in screening infrastructure.

Perioperative Skin Preparation

Liaison: Anthony T Tokarski BS Leaders: David Blaha MD (US), Michael A. Mont MD (US), Parag Sancheti MS, DNB, MCh (International) Delegates: Lyssette Cardona MD, MPH, MHA, AAHIVS, FIDSA, Gilberto Lara Cotacio MD, Mark Froimson MD, Bhaveen Kapadia MD, James Kuderna MD, PhD, Juan Carlos Lopez MD, Wadih Y Matar MD, MSc, FRCSC, Joseph McCarthy MD, Rhidian Morgan-Jones MB BCh, FRCS, Michael Patzakis MD, Ran Schwarzkopf MD, Gholam Hossain Shahcheraghi MD, Xifu Shang MD, Petri Virolainen MD, PhD, Montri D. Wongworawat MD, Adolph Yates Jr, MD

Impact of Preoperative MRSA Screening and Decolonization on Hospital-acquired MRSA Burden

Hospital-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are a source of morbidity and mortality. S. aureus is the most common pathogen in prosthetic joint infections and the incidence of MRSA is increasing. The purposes of this study were (1) to determine the MRSA prevalence density rate at a specialty orthopaedic hospital before and after the implementation of a screening and decolonization protocol,(2) to compare our prevalence density to that of an affiliated university hospital, to control for changes in MRSA prevalence density that might have been independent of the decolonization protocol, and (3) to measure the admission prevalence density rate of MRSA in an elective orthopaedic surgery population and the compliance rate of 26 patients with the protocol [corrected]. In October 2008, we implemented a MRSA screening and decolonization protocol for patients undergoing elective orthopaedic surgery. Nasal swabs were used for screening and mupirocin nasal ointment and chlorhexidine skin antisepsis where prescribed for decolonization to all patients. At the surgical visit, compliance was measured and the patients who were MRSA positive received vancomycin for antibiotic prophylaxis. Institution wide surveillance for multidrug-resistant organisms, including MRSA provided a comparison of the change in MRSA burden at the orthopaedic hospital versus the university hospital. Before implementation of the preoperative staphylococcal decolonization protocol there were 79 MRSA-positive cultures in 64,327 patient-days for a prevalence density rate of 1.23 per 1000 patient-days. After protocol implementation, 53 MRSA-positive cultures were identified in 63,860 patient-days for a rate of 0.83 per 1000 patient-days. Before the protocol, the MRSA prevalence density at the specialty hospital was similar to that of the university hospital; after implementation of the protocol, the prevalence density at the specialty hospital was 33% lower than that of the university hospital. The MRSA admission prevalence was 3.02%. The compliance rate was greater than 95%. Implementation of a staphylococcal decolonization protocol at a single specialty orthopaedic hospital decreased the prevalence density of MRSA.

A Clinical History of Methicillin-Resistant Staphylococcus aureus Is a Poor Predictor of Preoperative Colonization Status and Postoperative Infections

In the absence of established methicillin-resistant Staphylococcus aureus (MRSA) screening programs, many centers use a history of a positive culture or a nasal screen as a surrogate for preoperative MRSA colonization status. We aimed to evaluate the test characteristics of these surrogates. Retrospective cohort study. Veterans Affairs Boston Healthcare System surgical patients with a preoperative nasal MRSA polymerase chain reaction (PCR) screen. We assessed the performance of a history of a MRSA-positive culture or a positive nasal MRSA PCR screen during the year prior to surgery for predicting the preoperative nasal PCR screen result. The associations between MRSA history and postoperative outcomes, including MRSA cultures and infections, were also evaluated. Among 4,238 patients, a positive MRSA culture history had a sensitivity of 19.7% (95% confidence interval [CI], 15.4%-24.8%) and positive predictive value of 57.3% for the preoperative nasal MRSA status. The specificity of MRSA culture history was 99% (95% CI, 98.5%-99.2%). Prior-year nasal MRSA screen results had similar test characteristics. A history of a MRSA-positive culture was associated with an increased risk of postoperative MRSA-positive cultures (risk ratio [RR], 3.54 [95% CI, 1.70-7.37], [Formula: see text]) but not of infections (RR, 1.71 [95% CI, 0.58-5.01]), after adjustment for preoperative nasal MRSA status, vancomycin surgical prophylaxis, surgical scrub, and age. A history of a MRSA-positive culture and a positive nasal PCR screen are poor surrogate markers of preoperative colonization status, missing at least 70% of MRSA-colonized patients. Prior-year history is also not independently associated with MRSA-related postoperative infections. Strong consideration should be given to preoperative MRSA screening in patients at high risk for surgical complications.

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.

Clinical and cost ineffectiveness of preoperative screening for methicillin-resistant Staphylococcus aureus and intranasal mupirocin in preventing methicillin-resistant S aureus infections in cardiothoracic surgery

In our recent experience with methicillin-resistant Staphylococcus aureus (MRSA) infections in 488 patients undergoing thoracic cardiovascular surgery, we found only 2 MRSA infections (one sternal and one graft site). Both patients received preoperative bacitracin and had a negative nares culture for MRSA before the initiation of bacitracin therapy. We conclude that preoperative MRSA screening cultures and bacitracin prophylaxis are neither clinically efficacious nor cost-effective in predicting or preventing MRSA in patients undergoing thoracic cardiovascular surgery.

The Economic Effect of Screening Orthopedic Surgery Patients Preoperatively for Methicillin-ResistantStaphylococcus aureus

Patients undergoing orthopedic surgery are susceptible to methicillin-resistant Staphylococcus aureus (MRSA) infections, which can result in increased morbidity, hospital lengths of stay, and medical costs. We sought to estimate the economic value of routine preoperative MRSA screening and decolonization of orthopedic surgery patients. A stochastic decision-analytic computer simulation model was used to evaluate the economic value of implementing this strategy (compared with no preoperative screening or decolonization) among orthopedic surgery patients from both the third-party payer and hospital perspectives. Sensitivity analyses explored the effects of varying MRSA colonization prevalence, the cost of screening and decolonization, and the probability of decolonization success. Preoperative MRSA screening and decolonization was strongly cost-effective (incremental cost-effectiveness ratio less than $6,000 per quality-adjusted life year) from the third-party payer perspective even when MRSA prevalence was as low as 1%, decolonization success was as low as 25%, and decolonization costs were as high as $300 per patient. In most scenarios this strategy was economically dominant (ie, less costly and more effective than no screening). From the hospital perspective, preoperative MRSA screening and decolonization was the economically dominant strategy for all scenarios explored. Routine preoperative screening and decolonization of orthopedic surgery patients may under many circumstances save hospitals and third-party payers money while providing health benefits.

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.

Preoperative Methicillin-Resistant Staphylococcus aureus Screening in Mohs Surgery Appears to Decrease Postoperative Infections

Colonization with methicillin-resistant Staphylococcus aureus (MRSA) places patients at risk for postoperative MRSA wound infections. To determine the effect of a decontamination and prophylaxis protocol on postoperative MRSA wound infections in patients with nasal MRSA. Wound cultures over a 23-month period were reviewed before and 11 months after implementation of a screening and decontamination protocol. After preoperative MRSA screening with nasal swabs, carriers were instructed to use intranasal mupirocin for 5 to 7 days before surgery and 5 to 7 days of trimethoprim-sulfamethoxazole starting the day before surgery. During the 23 months before prescreening evaluation, we performed 3,633 Mohs surgical cases, and 12 postoperative MRSA wound infections (0.3%) occurred. Subsequently, 963 patients underwent screening for MRSA, and 23 MRSA carriers were identified (2.4%). Of the 22 who underwent the decontamination and treatment protocol, none developed postoperative wound infections. One MRSA carrier did not receive preoperative treatment and subsequently developed a MRSA wound infection. There were no other MRSA infections. Preoperative MRSA screening and implementation of a decontamination protocol appears to decrease postoperative MRSA wound infections after Mohs surgery. Although an interesting observation, controlled studies of clinical and cost effectiveness are required before general implementation. The authors have indicated no significant interest with commercial supporters.

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.