Staphylococcus aureus Screening and Decolonization for Prevention of Surgical Site Infections: A Surgeon's Perspective

Educational Objectives

The goal of this program is to improve management of patients with Staphylococcus aureus nasal colonization who are planning to undergo surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Screen patients undergoing planned surgery for S aureus colonization when indicated.
2. Prescribe preoperative S aureus decolonization therapy to minimize surgical site infections.
3. Select the best prophylactic antibiotics for patients with a history of S aureus colonization.

Summary

Staphylococcus aureus: nasal carriage is present in ≈33% of randomly selected people; prevalence is higher in persons with insulin-dependent diabetes mellitus, chronic peritoneal dialysis, intravenous drug use, liver dysfunction, or HIV infection; ≈20% of the general population are persistent carriers, ≈60% are intermittent carriers, and ≈20% are noncarriers; screening for methicillin-resistant S aureus (MRSA) before scheduled surgery is needed in some cases; the question is whether the focus should remain only on MRSA or extend to methicillin-sensitive S aureus (MSSA); Schweizer et al (2015) found that ≈20% of carriers have MRSA; S aureus nasal colonization is associated with an increased risk for surgical site infections (SSIs), and the risk increases with heavy colonization; when an SSI occurs, the same strain colonizing the nose is found at the infected site most of the time; therefore, eliminating S aureus from the nose may be helpful

Strategies: a meta-analysis (van Rijen et al [2008]) found that preoperative mupirocin use in carriers resulted in a decrease in infection risk of ≈45%; Bode et al (2010) compared patients with MSSA who had preoperative eradication with intranasal mupirocin ointment and chlorhexidine body wash vs controls and found that the SSI rate was significantly lower in the treatment group (2.5%) vs the control group (8%); mupirocin is recommended for decolonizing, and the standard of care is 5 days of treatment; however, it is challenging to ensure that patients use the treatment before surgery and to screen all patients and prescribe mupirocin before surgery; Phillips et al (2014) compared patients who were given mupirocin for 5 days preoperatively vs those who received a nasal swab with povidone-iodine in the preoperative holding area; the patients who received povidone-iodine had no deep infections and outperformed the mupirocin group; a possible reason is that all patients in the povidone-iodine group received effective treatment, while patients in the mupirocin group may not have been able to complete decolonization; in Maslow et al (2014), more patients in the mupirocin group also reported having an unpleasant experience compared with the povidone-iodine group

Decolonization and surgical prophylaxis: Murphy et al (2011) instituted a policy to screen for MRSA in all patients undergoing elective orthopedic surgery; all positive cases underwent 5 days of decolonization with nasal mupirocin and polymyxin 3 times per day and chlorhexidine body wash; patients could not undergo surgery until the MRSA screen was negative and had to be admitted for surgery ≤3 mo of the negative screen; they found that patients who needed decolonization had a significantly higher infection rate compared with those who were MRSA-negative at screening; cefuroxime was used for surgical prophylaxis; the study findings may have been because patients were allowed to wait ≤3 mo after decolonization and may have become recolonized and because cefuroxime is not effective against MRSA; in Schweizer et al (2015), all patients with MRSA or MSSA were decolonized and scheduled for operation soon after; those with MSSA were given a cephalosporin, and those with MRSA were given a cephalosporin and vancomycin; in hospitals that adhered to the protocol throughout, rates of S aureus infection decreased by 74%

Antibiotic resistance: giving mupirocin to all patients without screening carries the risk of causing antibiotic resistance; Lee et al (2011) reported that, after introduction of a MRSA decolonization program at one center, the rate of mupirocin resistance in S aureus recovered from their patients increased from 9% in 1999 to 81% in 2008; most had a relatively low level of resistance; some patients had persistent or recurrent MRSA after decolonization, and the combined mupirocin and chlorhexidine resistance resulted in a 3-fold higher failure of decolonization compared with patients who did not have persistence; photodisinfection of the nose with methylene blue may reduce infection rates but is not available in the United States yet; pharmaceutical companies are developing new nasal disinfectants that may have less susceptibility to generating resistance than mupirocin, but none are available for clinical use yet

Antibiotic prophylaxis: Finkelstein et al (2002) randomized patients to receive cefazolin or vancomycin as surgical prophylaxis; those who received vancomycin had a ≈3-fold higher infection rate with MSSA compared with those who got cefazolin, while patients who got cefazolin had twice as many MRSA infections compared with those who got vancomycin; a significant difference in bloodstream infections was also seen; retrospective analysis (Bull et al [2012]) reported that patients who received vancomycin had a 40% higher risk for infection compared with patients who were given other antibiotics; those who were given vancomycin had 2.7-fold more MSSA infections compared with those who received other antibiotics; while vancomycin is important to treat and prevent MRSA, it is less effective against MSSA than cephalosporins; 2013 antibiotic prophylaxis guidelines from the American Society for Health-System Pharmacology, Surgical Infection Society, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America (Bratzler et al [2013]) recommend that patients at increased risk for MRSA should have prophylaxis with vancomycin and cefazolin

Potentially preventable SSIs: an SSI is classified as potentially preventable if any known preventive measures, eg, prophylactic antibiotics, sterile instruments, normothermia, hyperoxia, and euglycemia, were available but not employed in the care of the patient; if a patient with nasal S aureus does not receive decolonization before surgery and has an SSI, it is considered potentially preventable; if a patient has or is at increased risk for MRSA but does not receive prophylactic vancomycin or vancomycin and cefazolin, an SSI that develops is considered potentially preventable; for scheduled clean operations with severe consequences from SSI, eg, cardiac surgery or hardware placement, screening for colonization is rational; positive results should be addressed with decolonization and the selection of the appropriate prophylactic antibiotic

Readings

Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362(1):9-17. doi:10.1056/NEJMoa0808939; Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt). 2013;14(1):73-156. doi:10.1089/sur.2013.9999; Finkelstein R, Rabino G, Mashiah T, et al. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thorac Cardiovasc Surg. 2002;123(2):326-332. doi:10.1067/mtc.2002.119698; Gomes ET, Carbogim FDC, Lins RS, et al. Effectiveness of supplemental oxygenation to prevent surgical site infections: A systematic review with meta-analysis. Rev Lat Am Enfermagem. 2022;30:e3648. doi:10.1590/1518-8345.6106.3648; Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, et al. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol. 2000;21(5):319-323. doi:10.1086/501763; Lee AS, Macedo-Vinas M, François P, Renzi G, Vernaz N, Schrenzel J, Pittet D, Harbarth S. Trends in mupirocin resistance in meticillin-resistant Staphylococcus aureus and mupirocin consumption at a tertiary care hospital. J Hosp Infect. 2011 Apr;77(4):360-2. doi: 10.1016/j.jhin.2010.11.002. Epub 2011 Jan 26. PMID: 21276638; Maslow J, Hutzler L, Cuff G, Rosenberg A, Phillips M, Bosco J. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014;37(6):e576-e581. doi:10.3928/01477447-20140528-59; Menz BD, Charani E, Gordon DL, et al. Surgical antibiotic prophylaxis in an era of antibiotic resistance: Common resistant bacteria and wider considerations for practice. Infect Drug Resist. 2021;14:5235-5252. doi:10.2147/IDR.S319780; Phillips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidemiol. 2014;35(7):826-832. doi:10.1086/676872; Portais A, Gallouche M, Pavese P, et al.Staphylococcus aureus screening and preoperative decolonisation with mupirocin and chlorhexidine to reduce the risk of surgical site infections in orthopaedic surgery: A pre-post study. Antimicrob Resist Infect Control. 2024;13(1):75. doi:10.1186/s13756-024-01432-2; Reiss S, Pané-Farré J, Fuchs S, et al. Global analysis of the Staphylococcus aureus response to mupirocin. Antimicrob Agents Chemother. 2012;56(2):787-804. doi:10.1128/AAC.05363-11; Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA. 2015;313(21):2162-2171. doi:10.1001/jama.2015.5387; van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;2008(4):CD006216. Published 2008 Oct 8. doi:10.1002/14651858.CD006216.pub2.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Dellinger was recorded exclusively for Audio Digest on July 17, 2024. Audio Digest thanks Dr. Dellinger for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GS712003

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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