Randomized clinical trial of preoperative intranasal mupirocin to reduce surgical-site infection after digestive surgery

Association between methicillin-resistant Staphylococcus aureus nasal carriage and infection after pancreatic surgery

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) infections after pancreatectomy are relatively rare; however, they can be fatal when associated with pseudoaneurysms. For the past 12 years, we have been investigating nasal MRSA carriage by polymerase chain reaction testing, postoperatively in patients admitted to the intensive care units, to prevent nosocomial infections. Here, we investigated the relationship between MRSA nasal carriage and postoperative MRSA infection at the surgical site, following pancreatectomy.

METHODS

This single-center retrospective study analyzed 313 pancreatectomies (220 pancreaticoduodenectomies and 93 distal pancreatectomies), performed at our hospital between January 2011 and June 2022. The incidence of surgical site infection (SSI) and postoperative MRSA infection were compared between the nasal MRSA-positive and nasal MRSA-negative groups.

RESULTS

MRSA nasal carriage was identified in 24 cases (7.6%), and the frequency of SSIs in the nasal MRSA-positive and MRSA-negative groups were 50% and 36.7%, respectively, with no significant difference (p = .273). However, the frequency of MRSA infection among the SSI cases was significantly higher in the nasal MRSA-positive group (16.7%) than in the nasal MRSA-negative group (1.7%) (p = .003).

CONCLUSION

It should be noted that MRSA carriers have a significantly higher frequency of MRSA-positive SSIs.

Drug delivery to the brain via the nasal route of administration: exploration of key targets and major consideration factors

Background

Cranial nerve-related diseases such as brain tumors, Alzheimer's disease, and epilepsy are serious diseases that continue to threaten human. Brain-related diseases are increasing worldwide, including in the United States and Korea, and these increases are closely related to the exposure to harmful substances and excessive stress caused by rapid industrialization and environmental pollution. Drug delivery to the brain is very important for the effective prevention and treatment of brain-related diseases. However, due to the presence of the blood-brain barrier and the extensive first-pass metabolism effect, the general routes of administration such as oral and intravenous routes have limitations in drug delivery to the brain. Therefore, as an alternative, the nasal-brain drug delivery route is attracting attention as a route for effective drug delivery to the brain.

Areas covered

This review includes physiological factors, advantages, limitations, current application status, especially in clinical applications, and the necessary factors for consideration in formulation development related to nasal-brain drug delivery.

Expert opinion

The nasal-brain drug delivery route has the advantage of enhancing drug delivery to the brain locally, mainly through the olfactory route rather than the systemic circulation. The nasal-brain lymphatic system has recently attracted attention, and it has been implied that the delivery of anticancer drugs to the brain nervous system is possible effectively. However, there are limitations such as low drug permeability, as well as nasal mucosa and the mucociliary system, as obstacles in nasal-brain drug delivery. Therefore, to overcome the limitations of nasal-brain drug delivery, the use of nanocarriers and mucoadhesive agents is being attempted. However, very few drugs have been officially approved for clinical application via the nasal-brain drug delivery route. This is probably because the understanding of and related studies on nasal-brain drug delivery are limited. In this review, we tried to explore the major considerations and target factors in drug delivery through the nasal-brain route based on physiological knowledge and formulation research information. This will help to provide a mechanistic understanding of drug delivery through the nasal-brain route and bring us one step closer to developing effective formulations and drugs in consideration of the key factors for nasal-brain drug delivery.

Management of post-surgical infection of onychocryptosis with topical application of hyaluronic acid versus antibacterial ointments

Introduction

The prevention and cure of postoperative infections has been a source of study over the years and is currently being studied. In this bibliographic review, a comparison between the different products used for the prevention and treatment of postsurgical infections has been procured, likewise, being able to determine which would be the best option for the treatment of post-surgical infections. In this bibliographic review we focus on Onychocryptosis because it is an emerging problem today. Many surgeries are performed to fix this condition, which increases the risk of infections.

Material

databases, including PubMed and Cochrane Library, as well as websites of international organizations, were searched up to January 2021. The search included studies and trials in humans on the use of hyaluronic acid and antibacterial ointments in various conditions or diseases.

Results

18 articles were analyzed individually, which included randomized studies of Hyaluronic Acid, various antibiotics and honey, and variables used topically. 3 articles were also selected to explain onychocryptosis and postoperative infections.

Conclusion

Despite being able to determine which antibiotic would be the best, and whether hyaluronic acid can be used for the prevention and/or cure of post-surgical infections, this review emphasizes that there is still a need for more specific studies on its use of these variables, both in post-surgical infections in general and in post-surgical onychocryptosis infections.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Article Commentary: The Continued Challenge of Staphylococcus aureus in the Surgical Patient

Staphylococcus aureus continues to be a common pathogen from community-acquired infections and for infections after surgical procedures. A review of the history of this pathogen indicates that it will likely continue to develop new virulence characteristics and that it will continue to develop new patterns of resistance. This presentation addresses the three major areas for surgeons in the future. First, vancomycin is losing its effectiveness against methicillin-resistant S. aureus (MRSA). The future antibiotic choices for treating this pathogen are discussed. Second, vancomycin is losing its effectiveness for prevention of MRSA infections at the surgical site, and another antibiotic choice needs to be developed for prevention of both methicillin-sensitive and methicillin-resistant staphylococci. Third, decolonization of staphylococci from the nasopharynx is discussed commonly in the literature, but valid evidence for this practice is limited. Controlled clinical trials to prevent surgical site infection by decolonization with mupirocin or other agents are needed. In summary, S. aureus will continue to challenge surgeons as an adaptable pathogen that can defy all of our treatment efforts.

Antimicrobial approaches in the prevention of Staphylococcus aureus infections: a review

Background

The prophylactic application of antimicrobials that are active against Staphylococcus aureus can prevent infections. However, implementation in clinical practice is limited. We have reviewed antimicrobial approaches for the prevention of S. aureus infections.

Methods

We searched the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE databases and trial registries using synonyms for S. aureus, infections and prevention as search terms. We included randomized controlled trials and systematic reviews only.

Results

Most studies were conducted with mupirocin. Mupirocin is effective in preventing S. aureus infections in patients receiving dialysis treatment and in surgical patients, particularly if the patients are carriers of S. aureus. The combination of mupirocin and chlorhexidine, but not chlorhexidine alone, is also effective against S. aureus infections. So far, vaccines have not proven successful in protecting against S. aureus infections. Regarding prophylactic povidone-iodine and systemic antibiotics, there is limited evidence supporting their effectiveness against S. aureus infections. Antimicrobial honey has not been proven to be more effective or non-inferior to mupirocin in protecting against S. aureus infections.

Conclusions

The current evidence supports the use of mupirocin as prophylaxis for preventing infections with S. aureus, particularly in carriers and in the surgical setting or in patients receiving dialysis treatment. Other antimicrobial agents have not been sufficiently proven to be effective so far, or have been proven ineffective. New trials with vaccines and anti-staphylococcal peptides are currently underway and may lead to new preventive strategies in the future.

Protecting patients from infection: Improving topical prophylaxis compliance on surgical wards

Background

At a medium-sized district general hospital in the heart of England, it was identified that compliance to the administration of topical prophylaxis on three general surgery wards had reduced to 23%, following implementation of an electronic medication prescription record. Therefore, a quality improvement project was commenced to improve this compliance to protect patients from meticillin-resistant Staphylococcus aureus (MRSA) colonisation and associated bacteraemia.

Aim

To improve compliance of topical prophylaxis administration on three surgical wards to protect patients from infection.

Method

Quality improvement plan - do - study - act (PDSA) cycles evaluated the effectiveness of four different strategies from baseline data which was 23% compliant in December 2016. These included teaching and communication strategies, prompts in medical notes, discontinuation of Mupirocin 2% nasal ointment as part of the topical prophylaxis regime and discontinuation of the topical wash lotion from requiring a prescription.

Results

The compliance of prophylaxis administration increased consistently throughout from 23% in December 2016 to 92% in March 2018. Consequently, the number of patients that developed a MRSA colonisation on the three wards reduced by 54%, from 13 in the 12 months before the study to six in the 12 months after the study.

Discussion

This study led to a change in the Trust MRSA Policy to better protect patients from infection, particularly surgical site infection and MRSA bacteraemia. It suggests that quality improvement methodology has a place in infection prevention practice.

Staphylococcus aureus nasal decolonization strategies: a review

Introduction: Staphylococcus aureus (S. aureus) infections are associated with increased morbidity, mortality and health-care costs. Persistent nasal carriage of S. aureus found in 10-30% of the general population, constitutes a risk factor for these infections. Nasal decolonization is one of the used strategies to prevent this risk in some situations. Areas covered: Mupirocin nasal ointment has been used for the nasal decolonization and prevention of staphylococcal infections in various settings like surgeries. However, rising rates of resistance to mupirocin require the development of new decolonization agents. In this review, we will discuss mupirocin, its origins, studies that proved its efficacy and the associated resistance, as well as other decolonization agents under investigation. Expert opinion: As some limitations exist to mupirocin use, further research for alternatives is encouraged. Some old approved antiseptics (chlorhexidine, povidone-iodine) or antibiotics (rifampicin, bacitracin) have been investigated for their efficacy in this indication. Other new agents (tea tree oil, retapamulin, LTX-109, XF-73, phages, lysostaphin, squalamine analogues, etc.) are being studied. Some of them are still in preclinical phases, and others have reached clinical trials, but further research is needed. Special interest should be given to single dose decolonization strategies and to molecules that do not select resistant strains.

Preoperative biliary colonization/infection caused by multidrug-resistant (MDR) pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection

BACKGROUND

The aim of this study was to review the surgical outcomes of patients who underwent major hepatectomy with extrahepatic bile duct resection after preoperative biliary drainage with a particular focus on the impact of preoperative biliary colonization/infection caused by multidrug-resistant pathogens.

METHODS

Medical records of patients who underwent hepatobiliary resection after preoperative external biliary drainage between 2001 and 2015 were reviewed retrospectively. Prophylactic antibiotics were selected according to the results of drug susceptibility tests of surveillance bile cultures.

RESULTS

In total, 565 patients underwent surgical resection. Based on the results of bile cultures, the patients were classified into three groups: group A, patients with negative bile cultures (n = 113); group B, patients with positive bile cultures without multidrug-resistant pathogen growth (n = 416); and group C, patients with multidrug-resistant pathogen-positive bile culture (n = 36). The incidence of organ/space surgical site infection, bacteremia, median duration of postoperative hospital stay, and the mortality rate did not differ among the three groups. The incidence of incisional surgical site infection and infectious complications caused by multidrug-resistant pathogens was significantly higher in group C than in groups A and B. Fifty-two patients had postoperative infectious complications caused by multidrug-resistant pathogens. Multivariate analysis identified preoperative multidrug-resistant pathogen-positive bile culture as a significant independent risk factor for postoperative infectious complications caused by multidrug-resistant pathogens (P< .001).

CONCLUSION

Major hepatectomy with extrahepatic bile duct resection after biliary drainage can be performed with acceptable rates of morbidity and mortality using appropriate antibiotic prophylaxis, even in patients with biliary colonization/infection caused by multidrug-resistant pathogens.

Decolonisation of MRSA and its effect on surgical site infections--a study in a tertiary care institute

BACKGROUND

Two-thirds of surgical site infections (SSI) because of Staphylococcus aureus are caused by Methicillin resistant Staphylococcus aureus (MRSA). This study was done to assess the efficacy of topical 2% mupirocin with 2% chlorhexidine gluconate body wash in decolonizing MRSA and its impact in preventing SSI because of MRSA. The various risk factors associated with MRSA carriers and SSI were also studied because of paucity of data in the developing world.

METHODS

We did a non-randomised interventional trial in 602 patients undergoing elective general surgical operations. All patients in case (297) group were screened for MRSA and those positive were decolonised with topical 2% mupirocin calcium ointment and daily baths with 2% chlorhexidine antiseptic solution for 5 days. Control (305) group patients underwent surgery without decolonisation. Postoperatively, all patients were followed up for SSI for 30 days.

RESULTS

Prevalence of MRSA carriers was 7.5% with decolonisation rate of 95.2%. The SSI incidence was 21.3%. The significant risk factors for SSI were type of anaesthesia (p = 0.002), duration of surgery (p = 0.001) and preoperative hospital stay (p = 0.001). There was a significant association between MRSA carrier positivity at the time of surgery and SSI (p = 0.041).

CONCLUSIONS

There was no reduction in rate of SSI or other nosocomial infections in patients undergoing elective general surgical operations following preoperative MRSA decolonisation with 2% mupirocin and 2% chlorhexidine gluconate in MRSA carriers. MRSA carrier status was a significant risk factor for SSI but not for other nosocomial infections.

Systematic literature analysis and review of targeted preventive measures to limit healthcare-associated infections by meticillin-resistant Staphylococcus aureus

Meticillin-resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections in Europe. Many examples have demonstrated that the spread of MRSA within healthcare settings can be reduced by targeted infection control measures. The aim of this systematic literature analysis and review was to summarise the evidence for the use of bacterial cultures for active surveillance the benefit of rapid screening tests, as well as the use of decolonisation therapies and different types of isolation measures. We included 83 studies published between 2000 and 2012. Although the studies reported good evidence supporting the role of active surveillance followed by decolonisation therapy, the effectiveness of single-room isolation was mostly shown in non-controlled studies, which should inspire further research regarding this issue. Overall, this review highlighted that when planning the implementation of preventive interventions, there is a need to consider the prevalence of MRSA, the incidence of infections, the competing effect of standard control measures (e.g. hand hygiene) and the likelihood of transmission in the respective settings of implementation.

Efficacy of pre-operative nasal staphylococcus aureus screening and chlorhexidine chest scrub in decreasing the incidence of post-resection empyema

BACKGROUND

We evaluated the efficacy of pre-operative Staphylococcus aureus (SA) screening and chlorhexidine chest scrub in decreasing the incidence of empyema after major pulmonary resections.

METHODS

For two years, a strategy aimed at decreasing post-resection empyema was instituted. This entailed pre-operative screening for nasal SA and chlorhexidine chest scrub the night before surgery (Group Swab-Scrub, n=192). Patients screened positive for SA, methicillin-resistant (MRSA) and methicillin-sensitive (MSSA), received 5 d of nasal mupirocin. Group Swab-Scrub was compared with patients two years earlier, who did not receive this pre-operative maneuver (Group Control, n=173). The extent of resection considered was lobectomy or greater. All patients received cefazolin (or clindamycin if allergic) prior to incision and 24 h postoperatively, except for patient in Group Swab-Scrub screening positive for MRSA, who received vancomycin. All patients had povidone-iodine skin preparation.

RESULTS

In Group Swab-Scrub, prevalence of nasal SA was 8.9% (17/192) two with MRSA and 15 with MSSA. There was no difference in patient demographics or operative characteristics between the Group Swab-Scrub and Group Control. There was also no difference in prolonged air-leak, empyema, wound infection, pneumonia, or mortality rates between the two groups. When stratifying for the extent of procedure, there was no difference in the incidence of empyema after lobectomy (Group Swab-Scrub, 3.9% [7/177] versus Group Control, 2.0% [3/151]; p=0.352) or pneumonectomy (Group Swab-Scrub, 6.7% [1/15] versus Group Control, 13.6% [3/22]; p=0.633). In both univariate and multivariable analysis, prolonged air-leak and pneumonectomy were significant risk factors for empyema.

CONCLUSIONS

Preoperative screening for nasal SA and chlorhexidine chest scrub does not seem to decrease empyema rates after major pulmonary resection. Prolonged air-leak and pneumonectomy continue to be significant risk factors for developing empyema. The number of patients undergoing pneumonectomy in this study is small and further studies are needed for this patient population.

Staphylococcal decolonisation: an effective strategy for prevention of infection?

Staphylococcus aureus decolonisation--treatment to eradicate staphylococcal carriage--is often considered as a measure to prevent S aureus infection. The most common approach to decolonisation has been intranasal application of mupirocin either alone or in combination with antiseptic soaps or systemic antimicrobial agents. Some data support the use of decolonisation in surgical patients colonised with S aureus, particularly in those undergoing cardiothoracic procedures. Although this intervention has been associated with low rates of postoperative S aureus infection, whether overall rates of infection are also decreased is unclear. Patients undergoing chronic haemodialysis or peritoneal dialysis might benefit from decolonisation, although repeated courses of treatment are needed, and the effects are modest. Eradication of meticillin-resistant S aureus (MRSA) carriage has generally been difficult, and the role of decolonisation as an MRSA infection control measure is uncertain. The efficacy of decolonisation of patients with community-associated MRSA has not been established, and the routine use of decolonisation of non-surgical patients is not supported by data.

The use of a critical care consult team to identify risk for methicillin-resistant Staphylococcus aureus infection and the potential for early intervention: a pilot study

OBJECTIVE

To test whether a critical care consult team can be used to identify patients who have methicillin-resistant Staphylococcus aureus nasal colonization during a window period at which they are at highest risk for methicillin-resistant S. aureus infection and can most benefit from topical decolonization strategies.

DESIGN

Prospective cohort study.

SETTING

Two adult tertiary care hospitals.

PATIENTS

Patients with at least one risk factor for methicillin-resistant S. aureus nasal colonization who were seen by a critical care consult team for potential intensive care unit admission were enrolled.

INTERVENTIONS

Nasal cultures for methicillin-resistant S. aureus were performed on all subjects. All subjects were followed for the development of a methicillin-resistant S. aureus infection for 60 days or until hospital discharge. Demographic and outcome data were recorded on all subjects.

MEASUREMENTS AND MAIN RESULTS

Two hundred subjects were enrolled. Overall 29 of 200 (14.5%) were found to have methicillin-resistant S. aureus nasal colonization. Methicillin-resistant S. aureus infections occurred in seven of 29 (24.1%) subjects with methicillin-resistant S. aureus nasal colonization vs. one of 171 (0.6%) subjects without methicillin-resistant S. aureus nasal colonization (p < .001). Methicillin-resistant S. aureus clinical specimens were recovered in 15 of 29 (51.7%) subjects with methicillin-resistant S. aureus nasal colonization vs. two of 171 (1.2%) without methicillin-resistant S. aureus nasal colonization.

CONCLUSIONS

A critical care consult team can be used to rapidly recognize patients with methicillin-resistant S. aureus nasal colonization who are at very elevated risk for methicillin-resistant S. aureus infection. The use of such a team to recognize patients who have greatest potential benefit from decolonization techniques might reduce the burden of severe methicillin-resistant S. aureus infections.

Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers

BACKGROUND

Staphylococcus aureus (S. aureus) is the leading nosocomial (hospital acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient's own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate nasal S. aureus.

OBJECTIVES

To determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2 2008), MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008) and CINAHL (1982 to May 2008). To identify unpublished trials, abstract books from major scientific meetings (ICAAC, ESCMID and SHEA) were handsearched, researchers and manufacturers of mupirocin were contacted and other electronic databases were searched (SIGLE, ASLIB Index, mRCT, USA Clinical Trials).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing nasal mupirocin with no treatment or placebo or alternative nasal treatment in the prevention of S. aureus infections in nasal S. aureus carriers were included.

DATA COLLECTION AND ANALYSIS

Titles, abstracts and full-text articles of studies retrieved from the search process were independently assessed by two authors for inclusion. From included studies a data extraction form was made and the quality of the trial was assessed. The primary outcome was the S. aureus infection rate (any site). Secondary outcomes were time to infection, mortality, adverse events and infection rate caused by micro-organisms other than S. aureus.

MAIN RESULTS

Nine RCTs involving 3396 participants met the inclusion criteria. Patient populations varied and several types of nosocomial S. aureus infection were described including bacteraemia, exit-site infections, peritonitis, respiratory tract infections, skin infections, surgical site infections (SSI) and urinary tract infections. After pooling the eight studies that compared mupirocin with placebo or with no treatment, there was a statistically significant reduction in the rate of S. aureus infection associated with intranasal mupirocin (RR 0.55, 95% CI 0.43 to 0.70).A planned subgroup analysis of surgical trials demonstrated a significant reduction in the rate of nosocomial S. aureus infection rate associated with mupirocin use (RR 0.55, 95% CI 0.34 to 0.89) however this effect disappeared if the analysis only included surgical site infections caused by S. aureus (RR 0.63, 95% CI 0.38 to 1.04), possibly due to a lack of power. The infection rate caused by micro-organisms other than S. aureus was significantly higher in patients treated with mupirocin compared with control patients (RR 1.38 95% CI 1.118 to 1.72).

AUTHORS' CONCLUSIONS

In people who are nasal carriers of S. aureus, the use of mupirocin ointment results in a statistically significant reduction in S. aureus infections.

A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections

Staphylococcus aureus (S. aureus) is an independent risk factor for orthopaedic surgical site infection (SSI). To determine whether a preoperative decolonization protocol reduces S. aureus SSIs, we conducted a prospective observational study of patients undergoing elective total joint arthroplasty (TJA) at our institution, with two control groups. The concurrent control group comprised patients of surgeons who did not participate in the intervention study. The preintervention control group comprised patients of participating surgeons who had undergone elective TJA during the year before the study. Patients in the intervention group were screened preoperatively for S. aureus by nasal swab cultures. S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine bath once daily for 5 days before surgery. All 164 of 636 participants (26%) who tested positive completed the decolonization protocol without adverse events and had no postoperative S. aureus SSIs at 1-year followup. In contrast, 1330 concurrent control patients had 12 S. aureus infections. If these infections had occurred in the 26% of patients expected to be nasal carriers of S. aureus at a given time, the infection rate would have been 3.5% (12 of 345) in the control group. In addition, the overall infection rate of the participating surgeons, including nonstaphylococcal infections, decreased from 2.6% during the preintervention period to 1.5% during the intervention period, translating to an adjusted economic gain of $231,741 for the hospital. The data suggest a preoperative decolonization protocol reduces S. aureus SSIs in patients undergoing TJA.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Preoperative use of mupirocin for the prevention of healthcare-associated Staphylococcus aureus infections: a cost-effectiveness analysis

OBJECTIVE

Staphylococcus aureus is the most common cause of healthcare-associated infections. Intranasal mupirocin treatment probably decreases S. aureus infections among colonized surgical patients. Using cost-effectiveness analysis, we evaluated the cost-effectiveness of preoperative use of mupirocin for the prevention of healthcare-associated S. aureus infections.

METHODS

Three strategies were compared: (1) screen with nasal culture and give treatment to carriers, (2) give treatment to all patients without screening, and (3) neither screen nor treat. A societal perspective was taken. Adverse outcomes included bloodstream infection, pneumonia, surgical site infection, death due to underlying illness or infection, readmission, and the need for home health care. Data inputs were obtained from an extensive MEDLINE review and from publicly available government data sources. The following base-case data inputs (and ranges) for sensitivity analysis were used: rate of S. aureus carriage, 23.1% (19%-55%); efficacy of mupirocin treatment, 51% (8%-75%); mupirocin treatment cost, 48.36 US Dollars (24.18-57.74 US Dollars); and hospital costs of bloodstream infection, 25,128 US Dollars (6,194-40,211 US Dollars), pneumonia, 18,366 US Dollars (5,574-28,952 US Dollars), and surgical site infection 16,256 US Dollars (5,119-22,553 US Dollars). Widespread use of mupirocin has been associated with high levels of mupirocin resistance; therefore, a broad range of estimates for efficacy was tested in the sensitivity analysis.

PATIENTS

The target population included patients undergoing nonemergent surgery requiring postoperative hospitalization.

RESULTS

Both the screen-and-treat and treat-all strategies were cost saving, saving 102 US Dollars per patient screened and 88 US Dollars per patient treated, respectively. In 1-way sensitivity analyses, the model was robust with respect to all data inputs except for the efficacy of mupirocin treatment. If the efficacy is less than 16.1%, then the screen-and-treat strategy is cost incurring. A treat-all strategy was more cost saving if the rate of S. aureus carriage was greater than 42.7%, the mupirocin cost was less than 29.87 US Dollars, or nursing compensation was greater than 64.21 US Dollars per hour.

CONCLUSION

Administration of mupirocin before surgery is cost saving, primarily because healthcare-associated infections are very expensive. The level of mupirocin efficacy is critical to the cost-effectiveness of this intervention.

Impact of prophylactic mupirocin for radical esophagectomy

The preoperative intranasal application of mupirocin significantly decreases the rate of nosocomial S. aureus infections among patients who are S. aureus carriers. However, it remains unclear whether the routine preoperative use of mupirocin would reduce postoperative S. aureus infections, especially methicillin-resistant Staphylococcus aureus (MRSA) infections, and who would benefit from the prophylactic use of mupirocin. Ninety-six consecutive patients who had undergone elective radical esophagectomy with right thoracotomy and laparotomy were evaluated. Fifty-one patients were given 2% mupirocin calcium ointment 3 times daily over 3 consecutive days before surgery. Uni- and multivariate analyses were performed to identify factors affecting the following three issues: postoperative MRSA infection, postoperative pneumonia, and the length of postoperative hospital stay. In univariate analyses, the preoperative application of mupirocin significantly reduced MRSA infection, postoperative pneumonia, and length of postoperative hospital stay. Multivariate analyses indicated significant associations between mupirocin administration and reductions in both MRSA infection and postoperative pneumonia, but not in length of postoperative hospital stay. Radical esophagectomy with right thoracotomy and laparotomy for esophageal carcinoma warranted the preoperative prophylactic administration of mupirocin in order to reduce postoperative infectious complications from MRSA. Its routine use for such a high-risk procedure is entirely reasonable.

Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis

OBJECTIVE

To review the evidence evaluating perioperative intranasal mupirocin for the prevention of surgical-site infections according to type of surgical procedure.

DESIGN

Systematic review and meta-analysis of published clinical trials.

SETTING

Studies included were either randomized clinical trial or prospective trials at a single institution that measured outcomes both before and after an institution-wide intervention (before-after trial). In all studies, intervention and control groups differed only by the use of perioperative intranasal mupirocin in the intervention group.

PATIENTS

Patients undergoing general or nongeneral surgery (eg, cardiothoracic surgery, orthopedic surgery, and neurosurgery).

MAIN OUTCOME MEASURE

Risk of surgical-site infection following perioperative intranasal mupirocin versus usual care.

RESULTS

Three randomized and four before-after trials met the inclusion criteria. No reduction in surgical-site infection rate was seen in randomized general surgery trials (summary estimates: 8.4% in the mupirocin group and 8.1% in the control group; relative risk [RR], 1.04; 95% confidence interval [CI95], 0.81 to 1.33). In nongeneral surgery, the use of mupirocin was associated with a reduction in surgical-site infection in randomized trials (summary estimates: 6.0% in the mupirocin group and 7.6% in the control group; RR, 0.80; CI95, 0.58 to 1.10) and in before-after trials (summary estimates: 1.7% in the mupirocin group and 4.1% in the control group; RR, 0.40; CI95, 0.29 to 0.56).

CONCLUSIONS

Perioperative intranasal mupirocin appears to decrease the incidence of surgical-site infection when used as prophylaxis in nongeneral surgery. Given its low risk and low cost, use of perioperative intranasal mupirocin should be considered in these settings.

New strategies to identify patients harbouring antibiotic-resistant bacteria at hospital admission

Nosocomial infections caused by antibiotic-resistant bacteria are associated with high morbidity and mortality worldwide. Most prevention strategies focus on cross-transmission, but the endemic state inside the hospital is also maintained through the influx of patients colonised or infected with antibiotic-resistant bacteria, balanced by the efflux of colonised patients following discharge. Epidemiological research has demonstrated that eradication can be achieved by preventing the influx of resistant bacteria. The presence of a central venous catheter and a history of methicillin-resistant Staphylococcus aureus (MRSA) infection or colonisation are associated significantly with methicillin-resistant staphylococcal bacteraemia at admission. Previous antibiotic therapy and transfer from long-term care facilities or nursing homes are associated with bacteraemia caused by methicillin-resistant coagulase-negative staphylococci, while skin ulcer and cellulites are independent risk-factors for MRSA bacteraemia. A scoring system using point values has been developed and validated to identify patients positive for vancomycin-resistant enterococci at admission. Six variables were identified: age > 60 years (2 points); hospitalisation in the previous year (3); use of two or more antibiotics during the previous 30 days (3); transfer from another hospital or long-term care facility (3); a requirement for chronic haemodialysis (2); and a previous history of MRSA infection (4). With a point score cut-off of > or = 10, the specificity of this prediction rule is 98%. Knowledge of variables identifying patients at high risk for being colonised or infected with antibiotic-resistant bacteria may assist clinicians in targeting preventive measures and streamlining the use of vancomycin. Current studies are analysing risk-factors for harbouring multiresistant Gram-negative bacteria at hospital admission.

Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project

In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting. The objectives were to review areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges. The workgroup reviewed currently published guidelines for antimicrobial prophylaxis. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection.

Control of endemic MRSA-what is the evidence? A personal view

Although there is extensive literature on the control of MRSA, when that concerning epidemics is excluded, only a limited amount remains regarding the control of endemic MRSA. Several guidelines have been recently published recommending stringent control measures, which are often suggested based on their success in controlling MRSA outbreaks in hospitals with few MRSA or in containing MRSA cases introduced into a hospital with no MRSA. In these settings, multiple measures are usually introduced with apparently successful results. However, results may not be generalizable to other settings and we do not know the minimum effective measures required for MRSA containment. This paper aims critically to review the literature to determine whether evidence exists for the value of the infection control measures that are widely recommended in the endemic setting. Much of this literature is based on observational studies, with few randomized, controlled trials having been conducted. More well-designed studies are required before many of the principles on which we build infection control programmes can be regarded as evidence based.

Nosocomial infection surveillance and control policies

PURPOSE OF REVIEW

In the majority of countries costs for health care are increasing and strategies to reduce adverse events in medical treatment have an increasing importance. Nosocomial infection remains the most common type of complication affecting hospitalized patients. As preventive strategies have indeed become more important they now have to show not only that they are effective in reducing nosocomial infections but also that they are cost effective. This paper investigates the contribution made by articles published in the last year to the development of nosocomial-infection surveillance and control policies.

RECENT FINDINGS

At least 15 randomized controlled studies and six meta-analyses investigating various infection-control policies were published last year. They did not lead to any changes in present guidelines, but rather endorsed existing recommendations. At least nine studies were found reporting a substantial reduction in nosocomial infections by the introduction of quality management principles under routine working conditions. Furthermore there were a lot of studies published which focused on optimizing surveillance measures and investigating the use of reference data for reducing infection rates. Only seven studies estimating the burden of disease were found in the literature of the past year.

SUMMARY

The predominant opinion voiced in the studies was that in many medical institutions some 30% or more of nosocomial infections could be prevented.

Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project

In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting. The objectives were to review areas of agreement among the most-recently published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the groups that have published North American guidelines for antimicrobial prophylaxis, as well as authors from several specialty colleges. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of SIPGWW include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.