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

Surgical Site Infection in Cardiac Surgery

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

Pre-surgical Nasal Decolonization of Staphylococcus aureus: A Health Technology Assessment

BACKGROUND

Staphylococcus aureus (S. aureus) is the most common cause of surgical site infections, and the nose is the most common site for S. aureus colonization. Pre-surgical (in the days prior to surgery) nasal decolonization of S. aureus may reduce the bacterial load and prevent the organisms from being transferred to the surgical site, thus reducing the risk of surgical site infection. We conducted a health technology assessment of nasal decolonization of S. aureus (including methicillin-susceptible and methicillin-resistant strains) with or without topical antiseptic body wash to prevent surgical site infection in patients undergoing scheduled surgery, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding nasal decolonization of S. aureus, and patient preferences and values.

METHODS

We performed a systematic literature search of the clinical evidence to retrieve systematic reviews and selected and reported results from one review that was recent, of high quality, and relevant to our research question. We complemented the chosen systematic review with a literature search to identify randomized controlled trials published since the systematic review was published in 2019. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review and the Cochrane risk-of-bias tool for randomized controlled trials to assess the risk of bias of each included primary study. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted both cost-effectiveness and cost-utility analyses using a decision-tree model with a 1-year time horizon from the perspective of Ontario's Ministry of Health. We also analyzed the budget impact of publicly funding nasal decolonization of S. aureus in pre-surgical patients in Ontario. To contextualize the potential value of nasal decolonization, we spoke with people who had recently undergone surgery, some of whom had received nasal decolonization, and one family member of a person who had recently had surgery. We also engaged participants through an online survey.

RESULTS

We included one systematic review and three randomized controlled trials in the clinical evidence review. In universal decolonization, compared with placebo or no intervention, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients undergoing orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of S. aureus carrier status (GRADE: Moderate to Very low). Compared with placebo, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, general, oncologic, gynaecologic, or neurologic surgery (GRADE: Moderate to Very low). In targeted decolonization, compared with placebo, nasal mupirocin combined with chlorhexidine body wash lowers the incidence of S. aureus-related surgical site infection (risk ratio: 0.32 [95% confidence interval: 0.16-0.62]) in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery (GRADE: High). Compared with no intervention, nasal mupirocin combined with chlorhexidine body wash in pre-surgical patients who are not S. aureus carriers undergoing orthopaedic surgery may have little to no effect on overall surgical site infection, but the evidence is very uncertain (GRADE: Very low). Most included studies did not separate methicillin-susceptible and methicillin-resistant strains of S. aureus. No significant antimicrobial resistance was identified in the evidence reviewed; however, the existing literature was not adequately powered and did not have sufficient follow-up time to evaluate antimicrobial resistance.Our economic evaluation found that universal nasal decolonization using mupirocin combined with chlorhexidine body wash is less costly and more effective than both targeted and no nasal decolonization. Compared with no nasal decolonization treatment, universal and targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would prevent 32 and 22 S. aureus-related surgical site infections, respectively, per 10,000 patients. Universal nasal decolonization would lead to cost savings, whereas targeted nasal decolonization would increase the overall cost for the health care system since patients must first be screened for S. aureus carrier status before receiving nasal decolonization with mupirocin. The annual budget impact of publicly funding universal nasal decolonization in Ontario over the next 5 years ranges from a savings of $2.98 million in year 1 to a savings of $15.09 million in year 5. The annual budget impact of publicly funding targeted nasal decolonization ranges from an additional cost of $0.08 million in year 1 to an additional cost of $0.39 million in year 5.Our interview and survey respondents felt strongly about the value of preventing surgical site infections, and most favoured a universal approach.

CONCLUSIONS

Based on the best evidence available, decolonization of S. aureus using nasal mupirocin combined with chlorhexidine body wash prior to cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery lowers the incidence of surgical site infection caused by S. aureus in patients who are S. aureus carriers (including methicillin-susceptible and methicillin-resistant strains) (i.e., targeted decolonization). However, nasal mupirocin alone may result in little to no difference in overall surgical site infections and S. aureus-related surgical site infections in pre-surgical patients prior to orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of their S. aureus carrier status (i.e., universal decolonization). No significant antimicrobial resistance was identified in the evidence reviewed.Compared with no nasal decolonization treatment, universal nasal decolonization with mupirocin combined with chlorhexidine body wash may reduce S. aureus-related surgical site infections and lead to cost savings. Targeted nasal decolonization with mupirocin combined with chlorhexidine body wash may also reduce S. aureus-related surgical site infections but increase the overall cost of treatment for the health care system. We estimate that publicly funding universal nasal decolonization using mupirocin combined with chlorhexidine body wash would result in a total cost savings of $45.08 million over the next 5 years, whereas publicly funding targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would incur an additional cost of $1.17 million over the next 5 years.People undergoing surgery value treatments aimed at preventing surgical site infections.

The effect of preoperative skin preparation on clinical outcomes with incisional surgery: a network meta-analysis

BACKGROUND

Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta-analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery.

METHODS

The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk-of bias (ROB2) assessment was used.

RESULTS

Twenty-nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09-1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment.

CONCLUSION

Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.

Selection of Staphylococcus aureus in a murine nasopharyngeal colonization model

Staphylococcus aureus nasal colonization is a risk factor for infection. A large proportion of the population are identified as potential S. aureus carriers yet we only partially understand the repertoire of genetic factors that promote long-term nasal colonization. Here we present a murine model of nasopharyngeal colonization that requires a low S. aureus inoculum and is amenable to experimental evolution approaches. We used this model to experimentally evolve S. aureus using successive passages in the nasopharynx to identify those genetic loci under selection. After 3 cycles of colonization, mutations were identified in mannitol, sorbitol, arginine, nitrite and lactate metabolism genes promoting key pathways in nasal colonization. Stress responses were identified as being under selective pressure, with mutations in DNA repair genes including dnaJ and recF and key stress response genes clpL, rpoB and ahpF. Peptidoglycan synthesis pathway genes also revealed mutations indicating potential selection for alteration of the cell surface. The murine model used here is versatile to question colonization, persistence and evolution studies. We studied the human pathogen Staphylococcus aureus in our search to determine factors that contribute to its ability to live in the human nose and throat. The anterior nares and nasopharynx are considered primary habitats but we do not understand how the pathogen adapts as it moves from one person to the next. We first determined sustained survival of the pathogen over multiple days in the nasopharynx that might act as a good model for human persistence due to the low numbers of bacteria needed for it to establish. By using successive rounds of colonization of the nasopharynx across different mice we revealed that multiple genetic changes in the S. aureus occurred. These changes were found in genes associated with the cell surface and metabolism and might indicate adaptation to the niche. One gene showed an accumulation of multiple mutations supporting a key contribution in adaptation but the role of the protein it encodes is not yet known. The contribution of these genes and genetic changes are unclear but indicate an area for future research to better understand how this common human pathogen is so successful at human colonization and survival.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Role of targeted and universal mupirocin-based decolonization for preventing surgical-site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis

The purpose of the present study was to provide a systematic literature review and pool evidence on the efficacy of mupirocin-based decolonization protocol in reducing surgical-site infections (SSIs) in patients undergoing cardiothoracic (CT) surgery based on their Staphylococcus (S.) aureus carrier state. The PubMed, Embase, Ovid, BioMed Central, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched for studies comparing mupirocin-based decolonization with controls for reducing SSIs in patients following CT surgery. Studies were grouped based on the targeted population of intervention, i.e. carriers or all patients. A total of 17 studies were included. Of these, 8 studies used targeted mupirocin-based decolonization, while universal decolonization was performed in 9 studies. The results were conflicting for studies performing targeted decolonization and it was not possible to perform a meta-analysis due to non-homogenous studies. Pooled analysis of 34,859 patients indicated that universal mupirocin-based decolonization significantly reduced the risk of all SSIs [risk ratio (RR): 0.54; 95% CI: 0.40,0.75; I²=73.35%]. The intervention significantly reduced the risk of superficial SSIs (RR: 0.37; 95% CI: 0.25,0.55; I²=0%) but not of deep SSIs (RR: 0.45; 95% CI: 0.19,1.09; I²=80.67%). The results indicated a significantly reduced risk of S. aureus SSIs (SA-SSIs) with mupirocin-based decolonization (RR: 0.44; 95% CI: 0.32,0.61; I²=0%) but not for methicillin-resistant S. aureus (MRSA-SSIs; RR: 0.25; 95% CI: 0.05,1.28; I²=79.07%). Evidence on the role of targeted mupirocin-based decolonization to reduce SSIs after CT surgery was non-coherent and inconclusive. Analysis of low-quality retrospective studies suggested that universal mupirocin-based decolonization may reduce all SSIs, superficial SSIs and SA-SSIs, but not deep SSIs or MRSA-SSIs in patients after CT surgery.

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

Background

Surgical 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).

Objective

To determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA.

Methods

Patients 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.

Results

Thirteen 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).

Conclusion

Universal 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 registration

The trial was registered at the German Registry for clinical studies www.drks.de (DRKS00011505).

Reduction in the infection rate of cranioplasty with a tailored antibiotic prophylaxis: a nonrandomized study

BACKGROUND

Cranioplasty carries a high risk of surgical site infections (SSIs) for a scheduled procedure, particularly with antibiotic-resistant bacteria.

METHODS

The goal of this retrospective study was to measure the effect of tailored antibiotic prophylaxis on SSIs resulting from cranioplasties. The authors collected a prospective database of cranioplasties from 2009 to 2018. Risk factors for SSI were registered, as well as infection occurring during the first year postoperatively. A new protocol was initiated in 2016 consisting of antibiotic prophylaxis tailored to the colonizing flora of the skin of the scalp and decolonization of patients who were nasal carriers of methicillin-resistant S. aureus (MRSA); infection rates were compared.

RESULTS

One hundred nine cranioplasties were identified, 64 in the old protocol and 45 in the new protocol. Of the 109 cranioplasties, 16 (14.7%) suffered an infection, 14 (21.9%) in the old protocol group and 2 (4.4%) in the new protocol group (OR for the new protocol 0.166, 95% CI 0.036-0.772). Multiple surgeries (OR 3.44), Barthel ≤ 70 (OR 3.53), and previous infection (OR 3.9) were risk factors for SSI. Of the bacteria identified in the skin of the scalp, 22.2% were resistant to routine prophylaxis (cefazoline). Only one patient was identified as a nasal carrier of MRSA and was decolonized.

CONCLUSIONS

A high percentage of bacteria resistant to routine prophylaxis (cefazoline) was identified in the skin of these patients' scalps. The use of tailored antibiotic prophylaxis reduced significantly the infection rate in this particular set of patients.

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

Aim

To 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.

Methods

Relevant 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.

Results

Twenty 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).

Conclusion

It 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.

A review of the management of patients with advanced heart failure in the intensive care unit

Despite progress in the medical and device therapy for heart failure (HF), the prognosis for those with advanced HF remains poor. Acute heart failure (AcHF) is the rapid development of, or worsening of symptoms and signs of HF typically leading to hospitalization. Whilst many HF decompensations are managed at a ward-based level, a proportion of patients require higher acuity care in the intensive care unit (ICU). Admission to ICU is associated with a higher risk of in-hospital mortality, and in those who fail to respond to standard supportive and medical therapy, a proportion maybe suitable for mechanical circulatory support (MCS). The optimal pre-operative management of advanced HF patients awaiting durable MCS or cardiac transplantation (CTx) is vital in improving both short and longer-term outcomes. This review will summarize the clinical assessment, hemodynamic profiling and management of the patient with AcHF in the ICU. The general principles of pre-surgical optimization encompassing individual systems (the kidneys, the liver, blood and glycemic control) will be discussed. Other factors impacting upon post-operative outcomes including nutrition and sarcopenia and pre-surgical skin decolonization have been included. Issues specific to durable MCS including the assessment of the right ventricle and strategies for optimization will also be discussed.

An Extended Duration of the Pre-Operative Hospitalization is Associated with an Increased Risk of Healthcare-Associated Infections after Cardiac Surgery

Nosocomial infections are a common complication in clinical practice with major impact on surgical success and patient outcome. The probability of nosocomial infections is rapidly increasing during hospitalization. Therefore, we investigated the impact of a prolonged pre-operative hospital stay on the development of post-operative infection. Within this prospective observational study, 200 patients scheduled for elective cardiac surgery were enrolled. Patients were followed during hospital admission and screened for the development of nosocomial infection. Logistic regression analysis was used to assess the impact of a prolonged pre-operative hospital stay on the development of infection. A total of 195 patients were suitable for the final analysis. We found a strong and direct association of the duration of pre-operative hospital stay and the number of patients developing infection (+23.5%; p = 0.006). Additionally, the length of patients’ pre-operative hospital stay was independently associated with the development of post-operative nosocomial infection, with an adjusted OR per day of 1.38 (95%CI: 1.02–1.86; p = 0.036). A prolonged pre-operative hospital stay was significantly associated with the development of nosocomial infection after cardiac surgery. Those findings need to be considered in future clinical patient management in order to prevent unnecessary antibiotic use and potential harm to patients.

[Antimicrobial activity of dioxidine and a dioxidin-containing preparation «Nosolin-Ultra, nasal drops».]

The study is devoted to the study of the antimicrobial activity of the antioxidant dioxidin and the complex dioxin-containing preparation Nosolin-ultra, nasal drops against planktonic and biofilm cultures of pathogens of ENT infections, the dynamics of the formation of microbial resistance to dioxidine. 11 reference strains and 9 clinical strains of microorganisms were used in the study: Streptococcus spp., Staphylococcus spp., Micrococcus luteus, Haemophilus influenzae, Acinetobacter pittii, Klebsiella pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa. The antimicrobial activity of preparations against planktonic cultures was determined by serial dilution in broth and spot method on solid nutrient media, against biofilms by the applicator method. The dynamics of dioxidine resistance formation was studied by passaging cultures in a liquid nutrient medium with increasing concentrations of antiseptic. Based on the study, it was found that Dioxidin showed antimicrobial activity against plankton cells of all strains (MBC=0.08-5 mg/ml), except S. pyogenes SN345 (MBC>5 mg/ml), inhibited the growth of formed biofilms (MBC=0.08-2.5 mg/ml) of all strains except S. pyogenes SN345 (MBC>5 mg/ml). The drug «Nosolin-ultra, nasal drops» was highly active against plankton cells (MBC=0.04-0.63 mg/ml) and biofilms (MBC=0.02-0.31 mg/ml) of gram-negative bacteria, except A. pittii (MBC>2.5 mg/ml), less active against plankton cells (MBC=1.25-2.5 mg/ml) and biofilms (MBC=0.02-0.31 mg/ml) of gram-positive bacteria and C. albicans. One strain (S. aureus) formed a variant resistant to dioxidine at a concentration of 20 mg/ml, which exceeded the concentration of dioxidine in the complex preparation; other strains (P. aeruginosa, K. pneumoniae, C. albicans) did not form such variants. The data obtained indicate that the drug «Nosolin-ultra, nasal drops» can be effectively used against most pathogens of ENT infections. It is worth noting that with prolonged use of the drug for some types of ENT pathogens in the future, a slight decrease in effectiveness may be noted.

[Perioperative antibiotic prophylaxis in dermatosurgery-2019 status quo]

Perioperative antibiotic prophylaxis (PAP) is determined as a short-term, in general single-shot administration of an antibiotic prior to a surgical intervention. The main goal of PAP is to reduce postoperative surgical site infections. In addition, PAP is administered to avoid development of bacterial endocarditis in patients who are at high risk. Regarding the increasing prescription of antibiotics by dermatologists and the rising emergence of resistant bacterial strains, a rational use of PAP in dermatosurgery has to be demanded. Thus, identification of risk factors being determined either by the patient, the type of surgery or the location will help to identify those patients requiring PAP. Moreover, utilizing established criteria will avoid the unnecessary administration of PAP-which only creates a false sense of safety.

Methicillin-resistant Staphylococcus aureus screening is important for surgeons

Backgrounds/Aims

Perioperative surgical site infection (SSI) remains a morbid complication even in successful surgical procedures. We encountered an unusual experience of a methicillin-resistant Staphylococcus aureus (MRSA)-related SSI outbreak in our hospital; therefore, we conducted an epidemiologic analysis to determine the origin of SSIs due to MRSA.

Methods

Among 102 consecutive patients who underwent hepatobiliopancreatic operations, SSIs occurred in eight cases. Infection surveillance regarding the operative environment was carried out. We analyzed the possible risk factors for this infectious outbreak in our institution.

Results

Patients with SSI tended to be older (p=0.293), had variable operation fields (p=0.020), more cancer-related operation (p=0.003), less laparoscopic surgery (p=0.007), performed in operation room 1 (p=0.004), prolonged operation time (p<0.001) and had longer hospital stays (p=0.002). After propensity score (PS) matching, there was the only significant difference in the participation of surgeon D as a second assistant (p=0.001) between the SSI and non-SSI group. After PS matching, surgeon D as a second assistant was the only significant risk factor for MRSA SSI in the univariate (p=0.001) and multivariate analysis (p=0.004, hazard ratio=25.088, 95% confidence interval=2.759-228.149).

Conclusions

Outbreak of SSIs occurred due to transmission of MRSA from a surgeon to patients despite the standard regulation of infection control. These SSIs were associated with an excessive incidence of surgeon's nasal and hand carriage of the MRSA strain identified in the surgeon via cultures. We recommend the preoperative regular nasal and hand screening for MRSA among surgeons.

Preoperative screening for nasal carriage of methicillin-resistant Staphylococcus aureus in patients undergoing general thoracic surgery

Objectives: Nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infections (SSIs). However, few studies have evaluated the rate of nasal carriage of MRSA and its effect on SSIs in patients undergoing general thoracic surgery. We investigated the importance of preoperative screening for nasal carriage of MRSA in patients undergoing general thoracic surgery.

Patients and Methods: We retrospectively analyzed 238 patients with thoracic diseases who underwent thoracic surgery. We reviewed the rates of nasal carriage of MRSA and SSIs.

Results: Results of MRSA screening were positive in 11 of 238 patients (4.6%), and 9 of these 11 patients received nasal mupirocin. SSIs occurred in 4 patients (1.8%). All 4 patients developed pneumonia; however, MRSA pneumonia occurred in only 1 of these 4 patients. No patient developed wound infection, empyema, and/or mediastinitis. SSIs did not occur in any of the 11 patients with positive results on MRSA screening.

Conclusions: The rates of nasal carriage of MRSA and SSIs were low in this case series. Surveillance is important to determine the prevalence of MRSA carriage and infection in hospitals, particularly in the intensive care unit. However, routine preoperative screening for nasal carriage of MRSA is not recommended in patients undergoing general thoracic surgery.

Increased Staphylococcus aureus Nasal Carriage Rates in Rheumatoid Arthritis Patients on Biologic Therapy

BACKGROUND

Rheumatoid arthritis patients are at increased risk for periprosthetic joint infection after arthroplasty. The reason is multifactorial. Nasal colonization with Staphylococcus aureus is a modifiable risk factor; carriage rates in RA patients are unknown. The goal of this study is to determine the S aureus nasal carriage rates of RA patients on biologics, RA patients on traditional disease-modifying anti-rheumatic drugs (DMARDs), and osteoarthritis.

METHODS

Consecutive patients with RA on biologics (±DMARDs), RA on non-biologic DMARDs, or OA were prospectively enrolled from April 2017 to May 2018. One hundred twenty-three patients were determined necessary per group to show a difference in carriage rates. Patients underwent a nasal swab and answered questions to identify additional risk factors. S aureus positive swabs were further categorized using spa typing. Logistic regression evaluated the association with S aureus colonization between the groups after controlling for known risk factors.

RESULTS

RA patients on biologics, 70% of whom were on DMARDs, had statistically significant increase in S aureus colonization (37%) compared to RA on DMARDs alone (24%), or OA (20%) (P = .01 overall). After controlling for glucocorticoids, antibiotic use, recent hospitalization, and diabetes, RA on biologics had a significant increased risk of S aureus nasal colonization (Odds ratio 1.80, 95% confidence interval 1.00-3.22, P = .047).

CONCLUSION

S aureus colonization risk was increased for RA on biologics compared to RA not on biologics and OA. Nasal S aureus carriage increases the risk of surgical site infection; this modifiable risk factor should be addressed prior to total joint arthroplasty for this higher risk patient group.

Surgical site infection: the "Achilles Heel" of all types of abdominal wall hernia reconstruction

PURPOSE

Surgical site infection is the most common hospital-acquired infection in surgical patients. Recently, public health organizations have updated prevention guidelines. This review discusses surgical site infections as a complication of abdominal wall reconstruction.

METHODS

The authors reviewed guidelines on prevention of surgical site infections from the Center for Disease Control and Prevention, World Health Organization, and National Institute for Health and Care Excellence and put them into context with the relevant abdominal wall reconstruction literature. This was the subject of the Nyhus-Wantz lecture given at The International Hernia Congress on March 14, 2018 in Miami, FL and is summarized here.

RESULTS

Routine use of preoperative antibiotics in prosthetic groin hernia repair is not supported by the available literature. High-quality data on antibiotic prophylaxis in ventral (both primary and incisional) hernia repair is lacking, but it is widely utilized and may reduce SSIs. Recommended preventative strategies discussed in this manuscript include: treatment of remote site infections, perioperative normothermia and normoglycemia, avoidance of hypoxemia, antiseptic preparation of surgical team hands and patient skin, treatment of obesity, smoking cessation, correction of malnutrition, and physical conditioning.

CONCLUSION

Surgical site infections lead to significant morbidity and mortality, hernia recurrences, prolonged hospital stay, and increased hospital costs. This makes surgical site infections the "Achilles Heel" of abdominal wall reconstruction. Strict adherence to standardized guidelines and preoperative optimization of patients' risk profiles are crucial to decrease the incidence of surgical site infections.

Impact of MSSA screening on rates of surgical site infection following lumbar spine surgery

PURPOSE

Methicillin-sensitive Staphylococcus aureus (MSSA) carriage may confer a significant risk of surgical site infection (SSI) and is common amongst the UK population. Screening for MSSA is not routinely offered to patients in the UK. Primary aim was to review the impact of introducing a MSSA screening programme, in addition to established Methicillin-resistant Staphylococcus aureus (MRSA) screening, on the incidence of SSIs following lumbar spine surgery.

METHODS

A consecutive group of 1307 patients during 12 months before (phase 1: n = 716) and after (phase 2: n = 591) introduction of the MSSA screening programme were compared. Analysis was restricted to those with inpatient stay greater than 4 days, readmission within 6 weeks and a rising CRP 7 or more days following the procedure. Diagnosis of SSI was based around the CDC guidelines for wound surveillance. Patients were excluded where the primary surgery was to treat infection, or the procedure was percutaneous. Chi-squared test was used to compare the two groups.

RESULTS

Seven hundred and sixteen patients were in phase 1. Rate of infection was 2.65%. Rate of MRSA colonisation was 0%. Five hundred and ninety-one patients were in phase 2. Rate of infection was 1.02%. Rate of MRSA colonisation was 0%, and rate of MSSA colonisation was 26%. Reduction in incidence of SSIs was 62% (p = 0.0409).

CONCLUSION

MSSA colonisation is common, although wound infection following lumbar spinal surgery remains a rare event. A screening programme for MSSA can significantly reduce incidence of SSIs in this patient group. These findings may be applicable to wider elective orthopaedic practice. These slides can be retrieved under Electronic Supplementary Material.