Nasal MRSA colonization: Impact on surgical site infection following spine surgery

Antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: an updated systematic review and meta-analysis

BACKGROUND

The efficacy and necessity of prophylactic antibiotics in clean and clean-contaminated surgery remains controversial.

METHODS

The studies were screened and extracted using databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials.gov according to predefined eligibility criteria. Randomized controlled trials (RCTs) comparing the effect of preoperative and postoperative prophylactic antibiotic use on the incidence of surgical site infections (SSIs) in patients undergoing any clean or clean-contaminated surgery.

RESULTS

A total of 16 189 participants in 48 RCTs were included in the primary meta-analysis following the eligibility criteria. The pooled odds ratio (OR) for SSI with antibiotic prophylaxis versus placebo was 0.60 (95% CI: 0.53-0.68). The pooled OR among gastrointestinal, oncology, orthopedics, neurosurgery, oral, and urology surgery was 3.06 (95% CI: 1.05-8.91), 1.16 (95% CI: 0.89-1.50), 2.04 (95% CI: 1.09-3.81), 3.05 (95% CI: 1.25-7.47), 3.55 (95% CI: 1.78-7.06), and 2.26 (95% CI: 1.12-4.55), respectively. Furthermore, the summary mean difference (MD) for patients' length of hospitalization was -0.91 (95% CI: -1.61, -0.16). The results of sensitivity analyses for all combined effect sizes showed good stability.

CONCLUSION

Antibiotics are both effective, safe, and necessary in preventing surgical wound infections in clean and clean-contaminated procedures, attributed to their reduction in the incidence of surgical site infections as well as the length of patient hospitalization.

Modifiable Preoperative Risk Factors to Mitigate Postoperative Site Infection Following Pediatric Gastrostomy

PURPOSE

There are limited studies assessing modifiable preoperative risk factors for pediatric laparoscopic gastrostomy tubes (LGT) and percutaneous endoscopic gastrostomy (PEG) tubes. We sought to evaluate the effect of demographics and surgical/infectious history on the superficial infection rate following gastrostomy tube (GT) placement.

METHODS

After IRB approval, we conducted a single-institution retrospective cohort study from 2015 to 2021 of pediatric patients undergoing LGT or PEG tube. The primary outcome was cellulitis or abscess formation within 30-days and 90-days postoperatively. Statistical analyses were performed with t-tests, Chi-squared, and logistic regression(p ≤ 0.05).

RESULTS

There were 382 patients, with 181 (47%) LGT and 201 (53%) PEGs. LGT patients were younger (5.9 vs. 12.3 months, p < 0.001) and more likely to be admitted to the neonatal or cardiac intensive care unit prior to their GT. There were similar rates of prior surgical intervention (58% vs. 66%, p = 0.29) and previous infection (37% vs. 38%, p = 0.87) in both LGT and PEG patients. Within 30-days postoperatively, LGT patients had a higher superficial infection rate (12% vs. 6%, p = 0.04). On multivariate regression, Black race (Odds Ratio 0.10, p = 0.03) was protective and prior Staphylococcus colonization (OR 2.35, p = 0.04) increased the odds of infection. In those patients colonized with Staphylococcus, 21% developed a superficial site infection compared to 9% in those not colonized (p = 0.01).

CONCLUSION

These data suggest prior Staphylococcus colonization is a significant risk factor for superficial infection following GT. Further work into preoperative decolonization strategies may provide an avenue to decrease the high infection rate in this common pediatric procedure.

LEVEL OF EVIDENCE

Level III.

Prevalence of surgical site wound infection after spine surgery in nasal colonization of methicillin-resistant Staphylococcus aureus: A meta-analysis

The purpose of the meta-analysis was to evaluate and compare the prevalence of surgical site infection (SSI) after spine surgery (SS) in nasal colonization of methicillin-resistant Staphylococcus aureus (MRSA). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random- or fixed-effect models. For the current meta-analysis, 14 examinations spanning from 2014 to 2022 were included, encompassing 18 410 people who were tested for nasal colonization after SS. MRSA-positive had a significantly higher SSI (OR, 3.65; 95% CI, 2.48-5.37, p < 0.001) compared with MRSA-negative in SS subjects. However, no significant difference was found between methicillin-susceptible Staphylococcus aureus and Staphylococcus aureus negative (OR, 0.94; 95% CI, 0.32-2.79, p = 0.91), and Staphylococcus aureus positive and negative (OR, 2.13; 95% CI, 0.26-17.41, p = 0.48) in SS subjects. The examined data revealed that MRSA colonization had a significant effect on SSI; however, methicillin-susceptible Staphylococcus aureus and Staphylococcus aureus had no significant effect on SSI in SS subjects. However, given that some comparisons included a small number of chosen studies, attention should be given to their values.

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.

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

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery.

SUMMARY OF BACKGROUND DATA

Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine.

MATERIALS AND METHODS

Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates.

RESULTS

This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA.

CONCLUSIONS

There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

Topical antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: a systematic review and meta-analysis

Background

Topical antibiotics are widely prescribed as prophylaxis for surgical site infection (SSI). Despite giving high drug concentrations at local wound sites, their efficacy remains controversial. This study is a systematic review and meta-analysis designed to compare the efficacy and safety of topical antibiotics with non-antibiotic agents in preventing SSI.

Methods

Randomized controlled trials (RCTs) comparing topical antibiotics in patients with clean and clean-contaminated postsurgical wounds were included. Relevant trials published before 30 September 2020, were searched in the PubMed, Embase, and Cochrane databases, without language restrictions. The primary outcome was the incidence of SSIs, presented as the event rate. The secondary outcome was the incidence of contact dermatitis (safety outcome). Data were synthesized using the random-effects model, with the results expressed as risk ratio (RR) with 95 per cent confidence intervals (c.i.).

Results

Thirteen RCTs were included. The incidence of SSIs and contact dermatitis showed no significant difference between topical antibiotics and non-antibiotic agents (RR 0.89, 95 per cent c.i. 0.59 to 1.32 (P = 0.56, I² = 48 per cent); and RR 2.79, 95 per cent c.i. 0.51 to 15.19 (P = 0.24, I² = 0 per cent), respectively). In the subgroup analyses, a reduction in SSIs was also not observed in dermatological (RR 0.77, 95 per cent c.i. 0.39 to 1.55; P = 0.46, I² = 65 per cent), ocular (RR 0.08, 95 per cent c.i. 0.00 to 1.52; P = 0.09), spinal (RR 1.34, 95 per cent c.i. 0.65 to 2.77; P = 0.43, I² = 0 per cent), orthopaedic (RR 0.69, 95 per cent c.i. 0.37 to 1.29; P = 0.25, I² = 0 per cent), or cardiothoracic surgeries (RR 1.60, 95 per cent c.i. 0.79 to 3.25; P = 0.19).

Conclusion

Given the current evidence, the routine application of topical antibiotics to surgical wounds did not reduce the incidence of SSI. Further trials are needed to assess their effectiveness in high-risk surgeries or in selected patient groups.

Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion

BACKGROUND CONTEXT

Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results.

PURPOSE

The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion.

STUDY DESIGN/SETTING

Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed.

OUTCOME MEASURES

The primary outcome was incision and drainage performed in the operating room within 90 days of surgery.

METHODS

MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate.

RESULTS

The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022).

CONCLUSIONS

The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.

Surgical Site Infection Prophylaxis and Wound Management in Spine Surgery

Surgical site infection (SSI) is a potentially devastating complication of spinal surgery that increases patient morbidity and healthcare costs. SSIs have complex and multifactorial etiologies; therefore, there are numerous opportunities for prevention and risk mitigation. The aim of this narrative review was to describe the incidence, risk factors, and outcomes of SSIs in spine surgery with an emphasis on postoperative wound care. We list and describe the preoperative, intraoperative, and postoperative evidence-based interventions that can be applied to potentially prevent SSI after spinal surgery.

Antibacterial apple cider vinegar eradicates methicillin resistant Staphylococcus aureus and resistant Escherichia coli

Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Escherichia coli (rE.coli) infections can spread rapidly. Further they are associated with high morbidity and mortality from treatment failure. Therapy involves multiple rounds of ineffective antibiotics alongside unwanted side effects, alternative treatments are crucial. Apple cider vinegar (ACV) is a natural, vegan product that has been shown to have powerful antimicrobial activity hence we investigated whether ACV could ameliorate these resistant bacteria. The minimum dilution of ACV required for growth inhibition was comparable for both bacteria (1/25 dilution of ACV liquid and ACV tablets at 200 µg/ml were effective against rE. coli and MRSA). Monocyte co-culture with microbes alongside ACV resulted in an increase in monocyte phagocytosis by 21.2% and 33.5% compared to non-ACV treated but MRSA or rE. coli stimulated monocytes, respectively. Label free quantitative proteomic studies of microbial protein extracts demonstrated that ACV penetrated microbial cell membranes and organelles, altering the expression of key proteins. This resulted in significant reductions in total protein expression, moreover we could only detect ribosomal proteins; 50 s 30 s, enolase, phosphenol pyruvate and the ATP synthase subunit in rE. coli. Elongation factor iNOS and phosphoglycerate kinase OS were the only proteins present in MRSA samples following ACV treatment.

Virulence Factors Found in Nasal Colonization and Infection of Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates and Their Ability to Form a Biofilm

Hospitalizations related to Methicillin-resistant Staphylococcus aureus (MRSA) are frequent, increasing mortality and health costs. In this way, this study aimed to compare the genotypic and phenotypic characteristics of MRSA isolates that colonize and infect patients seen at two hospitals in the city of Niterói—Rio de Janeiro, Brazil. A total of 147 samples collected between March 2013 and December 2015 were phenotyped and genotyped to identify the protein A (SPA) gene, the mec staphylococcal chromosomal cassette (SCCmec), mecA, Panton-Valentine Leucocidin (PVL), icaC, icaR, ACME, and hla virulence genes. The strength of biofilm formation has also been exploited. The prevalence of SCCmec type IV (77.1%) was observed in the colonization group; however, in the invasive infection group, SCCmec type II was prevalent (62.9%). The Multilocus Sequence Typing (MLST), ST5/ST30, and ST5/ST239 analyses were the most frequent clones in colonization, and invasive infection isolates, respectively. Among the isolates selected to assess the ability to form a biofilm, 51.06% were classified as strong biofilm builders. Surprisingly, we observed that isolates other than the Brazilian Epidemic Clone (BEC) have appeared in Brazilian hospitals. The virulence profile has changed among these isolates since the ACME type I and II genes were also identified in this collection.

Does preventive care bundle have an impact on surgical site infections following spine surgery? An analysis of 9607 patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The purpose was to analyze the effect of care bundle protocol on SSI in our institution. Postoperative surgical site infections (SSI) pose significant health burden. In spite of the use of prophylactic antibiotics, surgical advances and postoperative care, wound infection continues to affect patient outcomes after spine surgery.

METHODS

Retrospective analysis of 9607 consecutive patients who underwent spine procedures from 2014 to 2018 was performed. Preventive care bundle was implemented from January 2017 consisting of (a) preoperative bundle-glycemic control, chlorhexidine gluconate (CHG) bath, (b) intra-operative bundle-time specified antibiotic prophylaxis, CHG+ alcohol-based skin preparation (c) postoperative bundle-five moments of hand hygiene, early mobilization and bundle auditing. Patients operated from January 2017 were included in the post-implementation cohort and prior to that the pre-implementation cohort was formed. Data were drawn from weekly and yearly spine audits from the hospital infection committee software. Infection data were collected based on CDC criteria, further sub classification was done based on procedure, spinal disorders and spine level. Variables were analyzed and level of significance was set as < 0.05.

RESULTS

A total of 7333 patients met the criteria. The overall SSI rate decreased from 3.42% (131/3829) in pre-implementation cohort to 1.22% (43/3504, p = 0.0001) in post-implementation cohort (RR = 2.73, OR = 2.79). Statistically significant reduction was seen in all the groups (a) superficial and deep, (b) early and late and (c) instrumented and uninstrumented groups but was more pronounced in early (p = 0.0001), superficial (p = 0.0001) and instrumented groups (p = 0.0001). On subgroup analysis based on spine level and spinal disorders, significant reduction was seen in lumbar (p = 0.0001) and degenerative group (p = 0.0001).

CONCLUSIONS

Our study revealed significant reduction of SSI secondary to strict bundle adherence and monitored compliance compared to patients who did not receive these interventions.

LEVEL OF EVIDENCE

III.

Pre-operative methicillin resistant Staphylococcus aureus results do not predict surgical site infections in children undergoing varus derotational osteotomy

Literature regarding the value of pre-operative nasal methicillin resistant Staphylococcus aureus (MRSA) swabs to predict surgical site infections (SSIs) in children undergoing lower extremity surgery is limited. The purpose of our study was to determine if pre-operative nasal MRSA swab results were predictive of SSI development in children undergoing a femoral varus derotational osteotomy (VDRO).Patients who underwent VDRO between 2004-2016 were reviewed to determine pre-operative MRSA colonization rates and SSI devolvement rates. Patients with less than 1 year of follow-up, previous history of infections, or absent pre-operative MRSA swab were excluded. SSI rates of patients with negative MRSA and positive MRSA swab result were compared using the Fisher exact test. Aside from contact isolation precautions, no other changes in treatment were made during inpatient hospital course based on positive pre-operative nasal MRSA swab results.247 patients met the inclusion criteria (mean age: 9.3 ± 3.6 years, 62% male). There were 242 (98%) patients with a negative MRSA swab and 5 (2%) patients with a positive MRSA swab. Out of the 242 patients with a negative MRSA swab, 4 developed an SSI. Of the patients with positive MRSA swab results, 0% (0/5) developed an SSI compared to 1.7% (4/242) of negative MRSA swab results who developed an SSI. Results indicated no significant difference in SSI development rates between the groups (P = 1.00).In this series of children undergoing VDRO surgery, the results of a pre-operative MRSA nasal swab had no relationship to SSI incidence and no impact on clinical patient care. Pre-operative MRSA nasal swabs appear to be of limited benefit for routine pre-operative screening in this patient population.Level III, retrospective comparative.

Changes in Nasal Staphylococcus Colonization and Infection Rates After Nasal Surgery

Background: The relationship between nasal flora and infection rates in patients undergoing nasal surgery is of interest. This relationship has been studied though changes that may take place due to surgery have never been elucidated. Objective: To assess colonization rates and changes in colonization patterns of methicillin-resistant or methicillin-sensitive Staphylococcus aureus (MRSA/MSSA) in nasal flora in patients undergoing nasal surgery and to determine whether colonization is a risk factor for postoperative infection. Methods: Patients undergoing nasal surgery including septoplasty, rhinoplasty, or nasal valve repair were recruited prospectively. Patients completed a survey preoperatively concerning risk factors of postoperative infection. Nasal swabs and cultures were done preoperatively and at 1 week postoperatively. Patients were assessed for surgical site infections postoperatively. Results: Fifty-five patients completed both preoperative and postoperative nasal swabs. Preoperative to postoperative colonization rates increased for MRSA (2-5%) and MSSA (22-36%). Of the 55 patients, 11 had a change in nasal flora postoperatively, 9 of whom were colonized with a Staphylococcus aureus strain. However, MSSA/MRSA colonization either preoperatively or postoperatively was not associated with surgical site infections. Gender was the only variable found to be associated with postoperative infection (p = 0.007) with all four infections occurring in females. Conclusions: MSSA and MRSA do not appear to be major risk factors for surgical site infection in nasal surgery, whereas prior nasal surgery is a risk factor. This is the first report of a change in nasal colonization after nasal surgery. This could have implications for antibiotic prophylaxis in select nasal surgery cases.

Perioperative Strategies for Surgical Site Infection Prevention

Surgical site infections (SSIs) are some of the most common and costly health care-associated infections. Although the rate of SSIs has declined significantly in the past decade, patient safety remains at risk. Perioperative nurses employ a variety of evidence-based best practices to prevent SSIs and facilitate a safe surgical experience for their patients, including hand hygiene, preoperative patient skin antisepsis, and antimicrobial irrigation. This article explores the causes of SSIs, such as modifiable and nonmodifiable patient factors and preoperative, intraoperative, and postoperative procedural factors, and discusses some of the specific recommended strategies related to the prevention of SSIs that perioperative nurses can initiate in their workplace.

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

BACKGROUND CONTEXT

Nasal colonization of Staphylococcus aureus may increase the risk of surgical site infection (SSI) after spine surgeries, although the results of previous studies were inconsistent.

PURPOSE

To evaluate the influences of nasal colonization of S. aureus, methicillin-susceptible SA, and methicillin-resistant SA (MRSA) on the incidence of SSI after spine surgery.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

PATIENT SAMPLE

Seven studies including 10,650 patients who underwent nasal swab examination before spine surgeries were included, and 221 patients had nasal colonization of MRSA at baseline.

OUTCOME MEASURES

Association between baseline nasal colonization of S. aureus, MRSA, and SSI after spine surgery.

METHODS

Relevant follow-up studies were identified through systematic searches of the PubMed, Embase, and Cochrane Library databases. A random effects model was applied to pool the results. Subgroup analyses were performed according to whether MRSA decolonization was applied.

RESULTS

During follow-up, a total of 244 SSI events occurred, including 57 MRSA-SSI events. Pooled results showed that nasal S. aureus (risk ratio [RR]=0.75, p=.22) or methicillin-susceptible SA colonization (RR=0.60, p=.22) did not significantly affect the risk of overall SSI after surgeries. However, nasal MRSA colonization was associated with significantly increased risks of overall SSI and MRSA-SSI (RR=2.52 and 6.21, respectively, both p<.001). Interestingly, the associations between nasal MRSA colonization and increased risks of overall and MRSA-SSI remained significant in studies without MRSA decolonization, but became insignificant in studies with MRSA decolonization.

CONCLUSIONS

Nasal MRSA colonization may be associated with increased risks of overall SSI and MRSA-SSI after spine surgeries, and nasal MRSA decolonization may be associated with a reduction of SSI in these patients.

PREVALENCE OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN SPINAL SURGERY PATIENTS

ABSTRACT Objective The objective of this study was to determine the prevalence of patients with colonization of methicillin-resistant Staphylococcus aureus (MRSA) in the nasal mucosa, who underwent elective spinal procedures. Methods Retrospective study of the medical records of all patients submitted to elective procedures, totaling 125 individuals in the period of 2015 and 2017, performed by two spinal surgeons of the Orthopedics and Traumatology Service of Hospital Mater Dei, Belo Horizonte, Minas Gerais. The pre-operative investigation of MRSA consisted of the collection of a nasal swab for microbiological culture. Results Of the 125 patients evaluated, three (2.4%) showed positive results for MRSA nasal colonization. This prevalence is consistent with the international literature, that ranges from 1.5 to 5.9%. Of these patients none had infection of the surgical wound, probably due to the preoperative prophylactic measures. Conclusions Despite the limitations of the study, we found that the prevalence of carriers of this nasal MRSA population is similar to that of populations worldwide . Level of evidence III; Retrospective Study.

Can Methicillin-resistant Staphylococcus aureus Silently Travel From the Gut to the Wound and Cause Postoperative Infection? Modeling the "Trojan Horse Hypothesis"

OBJECTIVE

To determine whether intestinal colonization with methicillin-resistant Staphylococcus aureus (MRSA) can be the source of surgical site infections (SSIs).

BACKGROUND

We hypothesized that gut-derived MRSA may cause SSIs via mechanisms in which circulating immune cells scavenge MRSA from the gut, home to surgical wounds, and cause infection (Trojan Horse Hypothesis).

METHODS

MRSA gut colonization was achieved by disrupting the microbiota with antibiotics, imposing a period of starvation and introducing MRSA via gavage. Next, mice were subjected to a surgical injury (30% hepatectomy) and rectus muscle injury and ischemia before skin closure. All wounds were cultured before skin closure. To control for postoperative wound contamination, reiterative experiments were performed in mice in which the closed wound was painted with live MRSA for 2 consecutive postoperative days. To rule out extracellular bacteremia as a cause of wound infection, MRSA was injected intravenously in mice subjected to rectus muscle ischemia and injury.

RESULTS

All wound cultures were negative before skin closure, ruling out intraoperative contamination. Out of 40 mice, 4 (10%) developed visible abscesses. Nine mice (22.5%) had MRSA positive cultures of the rectus muscle without visible abscesses. No SSIs were observed in mice injected intravenously with MRSA. Wounds painted with MRSA after closure did not develop infections. Circulating neutrophils from mice captured by flow cytometry demonstrated MRSA in their cytoplasm.

CONCLUSIONS

Immune cells as Trojan horses carrying gut-derived MRSA may be a plausible mechanism of SSIs in the absence of direct contamination.

An empiric analysis of 5 counter measures against surgical site infections following spine surgery-a pragmatic approach and review of the literature

BACKGROUND CONTEXT

Surgical site infections (SSI) following spine surgery are debilitating complications to patients and costly to the healthcare system.

PURPOSE

Review the impact and cost effectiveness of 5 SSI prevention interventions on SSI rates in an orthopedic spine surgery practice at a major quaternary healthcare system over a 10-year period.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

All of the surgical patients of the 5 spine surgeons in our department over a 10-year period were included in this study.

OUTCOME MEASURES

SSI rates per year, standardized infection ratios (SIR) for laminectomies and fusions during the most recent 3-year period, year of implementation, and frequency of use of the different interventions, cost of the techniques.

METHODS

The SSI prevention techniques described in this paper include application of intrawound vancomycin powder, wound irrigation with dilute betadine solution, preoperative chlorhexidine gluconate scrubs, preoperative screening with nasal swabbing, and decolonization of S. aureus, and perioperative antibiotic administration. Our institution's infection prevention and control data were analyzed for the yearly SSI rates for the orthopedic spine surgery department from 2006 to 2016. In addition, our orthopedic spine surgeons were polled to determine with what frequency and duration they have been using the different SSI prevention interventions.

RESULTS

SSI rates decreased from almost 6% per year the first year of observation to less than 2% per year in the final 6 years of this study. A SIR of less than 1.0 for each year was observed for laminectomies and fusions for the period from 2013 to 2016. All surgeons polled at our institution uniformly used perioperative antibiotics, Hibiclens scrub, and the nasal swab protocol since the implementation of these techniques. Some variability existed in the frequency and duration of betadine irrigation and application of vancomycin powder. A cost analysis demonstrated these methods to be nominal compared with the cost of treating a single SSI.

CONCLUSIONS

It is possible to reduce SSI rates in spine surgery with easy, safe, and cost-effective protocols, when implemented in a standardized manner.

Incidence and risk factors associated with infection after intramedullary nailing of femoral and tibial diaphyseal fractures: Prospective study

BACKGROUND

Diaphyseal fractures of femur and tibia are prominent due to its high incidence and high economic and social impact. Intramedullary nailing (IN) is the surgical procedure of choice. Surgical site infection (SSI) related to this procedure is considered a difficult to treat complication.

AIMS

Determine the incidence of SSI after IN of femoral and tibial diaphyseal fractures and evaluate possible risk factors.

METHODS

Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months. Incidence of SSI was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification for open fractures, previous surgical manipulation, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for soft tissue reconstruction, use of negative pressure therapy) and microbiota-related factors (cultures of nasopharyngeal swabs forStaphylococcus aureus and axillary/inguinal/perineal swab for Acinetobacter baumannii).

RESULTS

221 patients were included and completed the 12-month follow-up period. Incidence of SSI was 11.8%. In the initial analysis by unadjusted logistic regression, following factors were associated SSI: Müller AO classification of the fracture morphology groups 2 or 3, previous use of external fixator, presence of drains, use of negative pressure therapy and need for muscle or skin flap repair. In the multiple logistic regression-adjusted analysis, previous use of external fixator and need for muscle or skin flap repair remained associated with SSI.

CONCLUSIONS

Incidence of SSI associated with IN for femoral and tibial diaphyseal fractures was 11.8%. Previous use of external fixators and need for muscle or skin flap repair were factors associated with occurrence of infection.

Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery

OBJECTIVE

Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings.

METHODS

A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group).

RESULTS

With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32–0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28–0.73; p = 0.0013).

CONCLUSIONS

A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.

Does Nasal Carriage of Staphylococcus aureus Increase the Risk of Postoperative Infections After Elective Spine Surgery: Do Most Infections Occur in Carriers?

BACKGROUND

Wound infections after adult spinal deformity surgery place a high toll on patients, providers, and the healthcare system. Staphylococcus aureus is a common cause of postoperative wound infections, and nasal colonization by this organism may be an important factor in the development of surgical site infections (SSIs). The aim is to investigate whether post-operative surgical site infections after elective spine surgery occur at a higher rate in patients with methicillin-resistant S. aureus (MRSA) nasal colonization.

METHODS

Consecutive patients undergoing adult spinal deformity surgery between 2011-2013 were enrolled. Enrolled patients were followed up for a minimum of 3 months after surgery and received similar peri-operative infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiologic data for each case of post-operative infection were gathered by direct medical record review. Local vancomycin powder was used in all patients and sub-fascial drains were used in the majority (88%) of patients.

RESULTS

1200 operative spine cases were performed for deformity between 2011 and 2013. The mean ± standard deviation age and body mass index were 62.08 ± 14.76 years and 30.86 ± 7.15 kg/m², respectively. 29.41% had a history of diabetes. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50% of all SSIs. Of the 34 (2.83%) cases of SSIs that were identified, only 1 case occurred in a patient colonized with MRSA.

CONCLUSION

Our study suggests that the preponderance of SSIs occurred in patients without nasal colonization by methicillin-resistant S. aureus. Future prospective multi-institutional studies are needed to corroborate our findings.

Methicillin-Resistant Staphylococcus aureus Nasal Swab and Suction Drain Tip Cultures in 4573 Spinal Surgeries: Efficacy in Management of Surgical Site Infections

STUDY DESIGN

A retrospective single-center study.

OBJECTIVE

To assess the diagnostic value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab and suction drain tip cultures.

SUMMARY OF BACKGROUND DATA

The prognostic value of MRSA nasal swab and suction drain tip cultures has not been firmly established in spinal surgery.

METHODS

This study retrospectively included 4573 consecutive patients who underwent spinal surgery between January 2008 and December 2014. Patients diagnosed with infectious disease were excluded. Prophylactic antibiotics were administered intraoperatively and postoperatively for 48 hours. MRSA nasal swab cultures were taken from all patients before surgery. Drains were removed when the volume of postoperative fluid drainage was less than 50 mL in the preceding 24 hours and cultures were made. Surgical site infection (SSI) was defined according to Centers for Disease Control and Prevention criteria.

RESULTS

SSI was identified in 94 cases (2.1%) and bacteria were isolated in 87 cases (92.6%). Positive MRSA nasal swab cultures were identified in 49 cases (1.1%). There was no significant difference in the SSI positivity rate between the MRSA nasal swab culture (+) and (-) groups. Positive drain tip cultures were found in 382 cases (8.4%), 28 of which developed SSI. There was a significant difference in the SSI positivity rate between the drain tip culture (+) and (-) groups. The sensitivity of drain tip culture was 29.8% and the specificity was 92.1%. In 16 of the 28 patients in the SSI (+) group with positive drain cultures, the same bacteria were isolated from the surgical site, giving a bacteria matching rate of 57.1%.

CONCLUSION

MRSA nasal swab and drain tip cultures were not useful for predicting SSI. However, drain tip culture had a high positivity rate in the SSI group and the coincidence rate for the causative pathogen was relatively high.

LEVEL OF EVIDENCE

4.

[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]

BACKGROUND

Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections.

METHODS

Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016).

RESULTS

Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m², increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis.

DISCUSSION

Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study.

CONCLUSION

In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.

Prediction of surgical site infection in spine surgery from tests of nasal MRSA colonization and drain tip culture

PURPOSE

MRSA is an organism that is a possible risk factor for postoperative SSI. The purpose of the study was to examine relationships among surgical site infection (SSI) after spinal surgery, nasal methicillin-resistant staphylococcus aureus (MRSA) colonization, and wound drain culture results.

METHODS

The subjects were 132 patients who underwent spinal instrumentation surgery. A preoperative nasal swab was used to check for the presence of MRSA colonization, and a wound drain tip culture was performed for detection of SSI. Data from culture studies using nasal samples and those from the distal tip of the wound drain were used for analysis.

RESULTS

Five patients (3.8%) had nasal MRSA, 17 (13%) had positive drain tip cultures, 15 (11%) had SSIs, and 10 (8%) had SSIs with MRSA. Patients with nasal MRSA had a higher rate of detection of bacteria in the drain tip culture (40 vs. 19%, p = 0.065), and the SSI rate was significantly higher in patients with a positive drain tip culture (33 vs. 10%, p = 0.012). The total SSI rate differed significantly between patients with and without nasal MRSA (40 vs. 10%, p = 0.039); however, the SSI with MRSA rate did not differ significantly between these groups.

CONCLUSION

MRSA carriers were not necessarily associated with MRSA infection, but were related to a positive drain tip culture and SSI, which might be due to endogenous skin bacteria. Therefore, possible SSI should be considered in patients with nasal MRSA colonization or bacteria detected in a drain tip culture.

Screening of methicillin-resistant Staphylococcus aureus nasal colonization among elective surgery patients in referral hospital in Indonesia

OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) colonization is associated with serious surgical site infection in high-risk patients. High prevalence of MRSA colonization was reported in many settings, nonetheless local data is required. The purpose of this study is to identify the prevalence and risk factor of MRSA nasal carriage in adult patients in National Referral Hospital in Indonesia before underwent elective surgical procedure.

RESULTS

From 384 patients, 16.9% patients of them had undergone orthopaedic surgery, 51.3% had received antibiotics within the previous 3-month and 41.1% patients had history of hospitalization within the previous 1 year. Total of 21.6% patients were on invasive devices for at least 48 h before the operation; 24.2% had an open wound; 19.3% patients were referred from other hospital/ward. Of these patients, solid tumor without metastasis was the most common factor identified by the Charlson index (38.3%). Nasal colonization of Gram-positive bacteria was detected in 76.8%; S. aureus in 15.6% of patients (n = 60). MRSA was identified in three isolates (0.8%) by both culture and polymerase chain reaction (PCR) tests. Due to low prevalence of MRSA nasal carriage, this finding supports the recommendation to not routinely apply mupirocin for nasal decolonization on patient planned for surgery in Indonesia.

Strategies to prevent infections associated with cardiovascular implantable electronic devices

INTRODUCTION

Infections involving cardiovascular implantable electronic devices (CIED) are associated with high morbidity and mortality and substantial financial cost. In the past two decades, the rate of CIED infections has increased disproportionate to the number of devices implanted, likely due to aging patient population with multiple comorbidities. Microbial contamination of the generator pocket and or leads by skin flora at the time of implantation is a major mechanism for early CIED infections. Due to resistance to host immune cells and antibiotics caused by biofilm formation, complete removal of the device generator and leads is required to achieve cure. Areas covered: In this manuscript, we review the published literature regarding epidemiology, risk factors, and pathogenesis of CIED infections with primary focus on the preventative strategies to reduce the incidence of device infections. Expert commentary: Strict adherence to infection control measures at the time of CIED implantation is critical in reducing the risk of device infection while adjunctive strategies such as use of antimicrobial envelopes might help in certain high-risk individuals. Technological advances in device manufacturing with availability of subcutaneous devices without transvenous leads and self-contained intracardiac devices without leads and generator show promise with lower risk of infection.

Perioperative participation of orthopedic patients and surgical staff in a nasal decolonization intervention to reduce Staphylococcus spp surgical site infections

With the goal of reducing rates of surgical site infections in our spine patients, we initiated a trial to investigate the impact of adding perisurgical nasal decolonization involving patients and surgical and nursing staff. We combined immediate presurgical application of a nonantibiotic alcohol-based nasal antiseptic with existing chlorhexidine bath or wipes in a comprehensive pre- and postoperative decolonization protocol. Mean infection rates were significantly decreased by 81% from 1.76 to 0.33 per 100 surgeries during the 15-month trial, when compared with the prior 9-month baseline.

Risk Factors for Surgical Site Infections Following Neurosurgical Spinal Fusion Operations: A Case Control Study

OBJECTIVE To determine risk factors for the development of surgical site infections (SSIs) in neurosurgery patients undergoing spinal fusion. DESIGN Retrospective case-control study. SETTING Large, academic, quaternary care center. PATIENTS The study population included all neurosurgery patients who underwent spinal fusion between August 1, 2009, and August 31, 2013. Cases were defined as patients in the study cohort who developed an SSI. Controls were patients in the study cohort who did not develop an SSI. METHODS To achieve 80% power with an ability to detect an odds ratio (OR) of 2, we performed an unmatched case-control study with equal numbers of cases and controls. RESULTS During the study period, 5,473 spinal fusion procedures were performed by neurosurgeons in our hospital. With 161 SSIs recorded during the study period, the incidence of SSIs associated with these procedures was 2.94%. While anterior surgical approach was found to be a protective factor (OR, 0.20; 95% confidence interval [CI], 0.08-0.52), duration of procedure (OR, 1.58; 95% CI, 1.29-1.93), American Society of Anesthesiologists score of 3 or 4 (OR, 1.79; 95% CI, 1.00-3.18), and hospitalization within the prior 30 days (OR, 5.8; 95% CI, 1.37-24.57) were found in multivariate analysis to be independent predictors of SSI following spinal fusion. Prior methicillin-resistant Staphylococcus aureus (MRSA) nares colonization was highly associated with odds 20 times higher of SSI following spinal fusion (OR, 20.30; 95% CI, 4.64-8.78). CONCLUSIONS In additional to nonmodifiable risk factors, prior colonization with MRSA is a modifiable risk factor very strongly associated with development of SSI following spinal fusion. Infect Control Hosp Epidemiol 2017;38:348-352.

Prior Staphylococcus Aureus Nasal Colonization: A Risk Factor for Surgical Site Infections Following Decolonization

INTRODUCTION

Staphylococcus aureus (S aureus) decolonization regimens are being used to mitigate the risk of surgical site infection (SSI). However, their efficacy is controversial, with mixed results reported in the literature.

METHODS

Before undergoing primary total knee arthroplasty (TKA), total hip arthroplasty (THA), or spinal fusion, 13,828 consecutive patients were screened for nasal S aureus and underwent a preoperative decolonization regimen. Infection rates of colonized and noncolonized patients were compared using unadjusted logistic regression. An adjusted regression analysis was performed to determine independent risk factors for SSI.

RESULTS

The rate of SSI in colonized patients was 4.35% compared with only 2.39% in noncolonized patients. In our TKA cohort, unadjusted logistic regression identified S aureus colonization to be a significant risk factor for SSI (odds ratio [OR], 2.9; P < 0.001). After controlling for other potential confounders including age, body mass index, tobacco use, and American Society of Anesthesiologists score, an SSI was 3.8 times more likely to develop in patients colonized with S aureus (OR, 3.8; P = 0.0025). The THA and spine colonized patients trended toward higher risk in both unadjusted and adjusted models; however, the results were not statistically significant.

DISCUSSION

The results of our study suggest that decolonization may not be fully protective against SSI. The risk of infection after decolonization is not lowered to the baseline of a noncolonized patient.

LEVEL OF EVIDENCE

Level IV.

Burden of Surgical Site Infections Associated with Select Spine Operations and Involvement of Staphylococcus aureus

BACKGROUND

Spine operations may be indicated for treatment of diseases including vertebral injuries, degenerative spinal conditions, disk disease, spinal misalignments, or malformations. Surgical site infection (SSI) is a clinically important complication of spine surgery. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), is a leading cause of post-spinal SSIs.

METHODS

PubMed and applicable infectious disease conference proceedings were searched to identify relevant published studies. Overall, 343 full-text publications were screened for epidemiologic, mortality, health care resource utilization, and cost data on SSIs associated with specified spine operations.

RESULTS

Surgical site infection rates were identified in 161 studies from North America, Europe, and Asia. Pooled average SSI and S. aureus SSI rates for spine surgery were 1.9% (median, 3.3%; range, 0.1%-22.6%) and 1.0% (median, 2.0%; range, 0.02%-10.0%). Pooled average contribution of S. aureus infections to spinal SSIs was 49.3% (median, 50.0%; range, 16.7%-100%). Pooled average proportion of S. aureus SSIs attributable to MRSA was 37.9% (median, 42.5%; range, 0%-100%). Instrumented spinal fusion had the highest pooled average SSI rate (3.8%), followed by spinal decompression (1.8%) and spinal fusion (1.6%). The SSI-related mortality rate among spine surgical patients ranged from 1.1%-2.3% (three studies). All studies comparing SSI and control cohorts reported longer hospital stays for patients with SSIs. Pooled average SSI-associated re-admission rate occurring within 30 d from discharge ranged from 20% to 100% (four studies). Pooled average SSI-related re-operation rate was 67.1% (median, 100%; range, 33.5%-100%). According to two studies reporting direct costs, spine surgical patients incur approximately double the health care costs when they develop an SSI.

CONCLUSIONS

Available published studies demonstrate a clinically important burden of SSIs related to spine operations and the substantial contribution of S. aureus (including MRSA). Preventive strategies aimed specifically at S. aureus SSIs could reduce health care costs and improve patient outcomes for spine operations.

Invasiveness Index as a Predictor of Surgical Site Infection after Spinal Fusion, Revision Fusion, or Laminectomy

OBJECTIVE To evaluate invasiveness index as a potential predictor of spine surgical site infection (SSI) after spinal fusion, revision fusion, or laminectomy. DESIGN Retrospective cohort study. SETTING Single, large, academic medical center. PATIENTS Adults undergoing spinal fusion, revision fusion, or laminectomy. METHODS Data were obtained from electronic hospital databases; cases of SSI were extracted from the infection control database using National Healthcare Safety Network (NHSN) definitions. For each case, an invasiveness index, determined by surgical approach, procedure, and number of spine levels treated, was calculated using current procedural terminology (CPT) billing codes. Statistical analyses were performed using univariate and multivariate logistic regression models. RESULTS In total, 3,143 patients met inclusion criteria, and 43 of these developed SSI. Multivariate regression showed that advanced age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.005-1.05, for each year of life) and invasiveness index (medium invasiveness index OR, 5.36; 95% CI, 1.92-14.96; high invasiveness index OR, 14.1; 95% CI, 4.38-45.43) were significant predictors of infection. In subgroup analyses of spinal fusion patients, morbid obesity (OR, 2.542; 95% CI, 1.08-5.99), trauma (OR, 2.41; 95% CI, 1.05-5.55), and invasiveness index (medium invasiveness index OR, 5.39; 95% CI, 1.56-18.61; high invasiveness index OR, 13.44; 95% CI, 3.28-55.01) were significant predictors of SSI. Models containing invasiveness index were compared to NHSN models and demonstrated similar performance. CONCLUSIONS Invasiveness index is a predictor of SSI after spinal fusion and performs similarly to NHSN models. Invasiveness index shows promise as a potential risk stratification tool that is easily calculated and is available preoperatively. Infect Control Hosp Epidemiol 2016:1-7.

Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money?

OBJECTIVES

To review the use of preoperative screening for Staphylococcus aureus for all pediatric spine procedures that was instituted at our facility in a multimodal approach to decrease the frequency of postoperative wound infections.

SUMMARY OF BACKGROUND DATA

Four years ago at our facility, a multimodal approach to decrease the frequency of postoperative infections after pediatric spine surgery was instituted.

METHODS

A single-center, single-surgeon pediatric spine surgery database was queried to identify all patients who had preoperative S. aureus nasal swab screening. Data collected included demographic data, diagnoses, methicillin-resistant S. aureus (MRSA) swab findings, bacterial antibiotic sensitivities, and outcome of the spine surgery.

RESULTS

A total of 339 MRSA screenings were performed. Twenty (5.9%) were MRSA positive, and 55 (16.2%) were methicillin-sensitive S. aureus (MSSA) positive. In the MRSA-positive group, 13 were neuromuscular, 5 were adolescent idiopathic scoliosis (AIS), 1 congenital, and 1 infantile idiopathic scoliosis. Of the MRSA-positive screenings, 13 (65.0% of MRSA-positive screenings; 3.8% of entire cohort) of were newly identified cases (9 neuromuscular, 3 AIS, and 1 congenital diagnoses). In the 55 MSSA-positive, 6 documented resistance to either cefazolin or clindamycin. Hence, in up to 22 of the preoperative screenings (6.5% of entire cohort; 16 MRSA and 6 MSSA showed antibiotic resistance), the preoperative antibiotic regimen could be altered to appropriately cover the identified bacterial resistances. During the study period, there were 11 patients who were diagnosed with a postoperative deep wound infection, none of them having positive screenings.

CONCLUSION

The use of preoperative nasal swab MRSA screening permitted adjustment of the preoperative antibiotic regimen in up to 6.5% of patients undergoing pediatric spine surgery. This inexpensive, noninvasive tool can be used in preoperative surgical planning for all patients undergoing spinal procedures.

LEVEL OF EVIDENCE

Level IV.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.

Risk factors for, and the effect of MRSA colonization on the clinical outcomes of severely burnt patients

BACKGROUND

MRSA is an on-going problem for burn patients.

AIM

To analyze risk factors for, and the effect of MRSA colonization on burn patients' outcome.

METHODS

During 21 months burn patients' details and MRSA isolates were analyzed, and a case-control study performed.

RESULTS

Of 357 burn patients, 57 (16%) tested positive for MRSA. Compared to the MRSA negative group, MRSA positive patients had a higher median total burn surface area (15%[IQR 5-17%] vs. 5%[IQR 2-8%]; p<0.001), more admissions to ICU (54% vs. 26%; p<0.001), longer ICU length of stay (4.3 vs. 1.0 days; p<0.001), required more operations (1.6 vs. 0.8; p<0.001), and had longer total hospital length of stay (25.5 vs. 8.0 days; p<0.001). MRSA positivity was a significant independent predictor of increased length of stay (6.0 days, 95%CI 2.39-9.6 days; p=0.001) in a multivariable regression model correcting for patients TBSA and co-morbidities. Cardiac comorbidities (OR 5.14, 95%CI 1.76-15.62; p<0.001) and a longer exposure to the hospital environment (OR 1.05, 95%CI 1.02-1.09, p=0.005) increased the likelihood for MRSA positivity.

CONCLUSION

The negative impact of MRSA positivity on burn patients outcome indicates the need for improved screening procedures for early identification and further efforts toward MRSA infection control to prevent cross-infection as this may significantly impair patients' outcome.