Process improvement plan for the reduction of sternal surgical site infections among patients undergoing coronary artery bypass graft surgery

Intranasal Mupirocin to Reduce Surgical Site Infection Post Cardiac Surgery: A Review of the Literature

Sternal wound infections after cardiac surgery are associated with high rates of morbidity and mortality. One of the known risk factors of sternal wound infection is Staphylococcus aureus colonisation. Intranasal mupirocin decolonisation therapy implemented pre-operatively appears to be an effective preventative measure in reducing sternal wound infections post-cardiac surgery. Therefore, the main aim of this review is to evaluate the current literature regarding the use of intranasal mupirocin before cardiac surgery and its impact on sternal wound infection rates.

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

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

Implementation strategies to reduce surgical site infections: A systematic review

BACKGROUND

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence.

OBJECTIVE

To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs.

DESIGN

Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate).

RESULTS

In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers.

CONCLUSIONS

Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

Prevention of deep sternal wound infection in cardiac surgery: a literature review

BACKGROUND

Deep sternal wound infection (DSWI) is a dreaded complication of cardiac surgery with considerable consequences in terms of mortality, morbidity and treatment costs. In addition to standard surgical site infection prevention guidelines, multiple specific measures in the prevention of DSWI have been developed and evaluated in the past decades. This review focuses on these specific measures to prevent DSWI.

METHODS

An extensive literature search was performed to assess interventions in the prevention of DSWI. Articles describing results of a randomized controlled trial were categorized by type of intervention. Results were yielded and, if possible, pooled.

RESULTS

From a total of 743 articles found, 48 randomized controlled trials were selected. Studies were divided into 12 categories, containing pre-, peri- and postoperative preventive measures. Specific measures shown to be effective were: antibiotic prophylaxis with a first-generation cephalosporin for at least 24 h, application of local gentamicin before chest closure, sternal closure with figure-of-eight steel wires, and postoperative chest support using a corset or vest.

CONCLUSION

This study identified several measures that prevent DSWI after cardiac surgery that are not frequently applied in current practice. It is recommended that the guidelines on prevention of surgical site infection in cardiac surgery should be updated.

An economic evaluation of two interventions for the prevention of post-surgical infections in cardiac surgery

OBJECTIVE

To conduct a cost-effectiveness analysis that compares two prophylactic protocols for treating post-surgical infections in cardiac surgery.

METHODS

A cost effectiveness analysis was done by using a decision tree to compare two protocols for prophylaxis of post-surgical infections (Protocol A: Those patient with positive test to methicillin-resistant Staphylococcus aureus (MRSA) colonization received muripocin (twice a day during a two-week period), with no follow-up verification. Those who tested negative did not receive the prophylaxis treatment; Protocol B: all patients received the mupirocin treatment). The number of post-surgical infections averted was the measure of effectiveness from the health system's perspective, 30 days following the surgery. The incidence of infections and complications was obtained from two cohorts of patients who underwent cardiac surgery Hospital. The times for applying the two protocols were validated by experts. They cost were calculated from the hospital's analytical accounting management system and Pharmaceutical Service. Only direct costs were taken into account, no discount rates were applied. Incremental cost-effectiveness ratio (ICER) was calculated. A probabilistic sensitivity analysis was performed.

RESULTS

A total of 1118 patients were included (721 in Protocol A and 397 in Protocol B). No statistically significant differences were found in age, sex, diabetes, exitus or length of hospital stay between the two protocols. In the control group the rate of infection was 15.3%, compared with 11.3% in the intervention group. Protocol B proves to be more effective and at a lower cost, yielding an ICER of €32,506.

CONCLUSION

Universal mupirocin prophylaxis against surgical site infections (SSI) in cardiac surgery as a dominant strategy, because it shows a lower incidence of infections and cost savings, versus the strategy to treat selectively patients according to their test results prior screening.

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.

Improving Outcomes of Coronary Artery Bypass Graft Infections With Multiple Interventions Putting Science and Data to the Test

In 2001, 7.58% of our coronary artery bypass graft (CABG) patients developed surgical-site infection (SSI) as compared with 3.57% in National Nosocomial Infections Surveillance System hospitals from January 1992 to June 2001. Seven new preventive measures were implemented and in 2002, the rate was 3.47%. Implementing evidence-based measures improved patient outcomes.

Surgical site infections: incidence and trends at a community teaching hospital

BACKGROUND

There has been increased national attention on methicillin-resistant Staphylococcus aureus (MRSA) and surgical site infections (SSIs) highlighted by the media, the public, and federal agencies. It was therefore considered important to analyze the trends and incidence of inpatient detected SSIs and associated resistant organisms at our own institution.

METHODS

The analysis reflects the cultures and sensitivities of SSI on the surgical services at Monmouth Medical Center, a 527-bed community teaching hospital, from January 2003 through December 2007. The SSIs included in the study were those detected in hospitalized patients.

RESULTS

There were 312 surgical patients who developed SSIs. Contrary to observed national trends, our study demonstrated a statistically significant decrease in the incidence of MRSA among all the surgical services. We also noted a statistically significant decrease trend of SSIs in orthopedic surgery. The 312 patients' cultures yielded 399 bacterial strains. The most common strains varied with the service. Overall, the most common isolate identified was Staphylococcus species, numbering 143% or 35.8% of all isolates. MRSA was identified in 46 SSIs and 8 SSIs were positive for vancomycin-resistant enterococci (VRE).

CONCLUSIONS

Only a hospital-specific SSI analysis can help focus improvement with clinical impact. The scrutiny of SSI analysis has highlighted SSI problems in the pediatric and orthopedic surgery services that have been addressed.

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m(2) (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.

Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients

BACKGROUND

Staphylococcus aureus (S aureus) is the major cause of surgical site infections (SSI). At The Christ Hospital, Cincinnati, OH, S aureus accounted for over 80% of sternal wound infections in cardiac surgery patients. Approximately 700 cardiac surgeries are performed each year, with an associated infection rate of 1.8% per 100 procedures performed. In an attempt to reduce S aureus sternal wound infections, the use of prophylactic intranasal mupirocin was examined.

METHODS

Each patient undergoing cardiac surgery was nasally cultured before entering the operating room, and then intranasal mupirocin was applied and continued every 12 hours. Culture results were finalized within 48 hours. Mupirocin was discontinued when the culture returned negative and continued for 7 days when the culture returned positive for S aureus.

RESULTS

Cultures showed a S aureus carrier rate of 21%. These patients received mupirocin for 7 days. A decrease in S aureus-associated SSI rates was observed from a case rate of 1.68% to 0.37% per 100 procedures over a 17-month period.

CONCLUSION

Identifying and treating S aureus carriers with a full course of mupirocin does impact the rate of S aureus surgical site infections.

Multicenter experience: prevention and management of left ventricular assist device infections

Implantable left ventricular assist devices (LVADs) have demonstrated clinical success in both the bridge-to-transplantation and destination-therapy patient populations; however, infection remains one of the most common causes of mortality during mechanical circulatory support. Thus, serious LVAD infections may negate the benefits of LVAD implantation, resulting in decreased quality of life, increased morbidity and mortality, and increased costs associated with implantation. Prevention of device-related infection is crucial to the cost-effective use of mechanical circulatory support devices. Therefore, adherence to evidence-based infection control and prevention guidelines, meticulous surgical technique and optimal postoperative surgical site care form the foundation for LVAD associated infection prevention.

A Systematic Review of Quasi-Experimental Study Designs in the Fields of Infection Control and Antibiotic Resistance

We performed a systematic review of articles published during a 2-year period in 4 journals in the field of infectious diseases to determine the extent to which the quasi-experimental study design is used to evaluate infection control and antibiotic resistance. We evaluated studies on the basis of the following criteria: type of quasi-experimental study design used, justification of the use of the design, use of correct nomenclature to describe the design, and recognition of potential limitations of the design. A total of 73 articles featured a quasi-experimental study design. Twelve (16%) were associated with a quasi-experimental design involving a control group. Three (4%) provided justification for the use of the quasi-experimental study design. Sixteen (22%) used correct nomenclature to describe the study. Seventeen (23%) mentioned at least 1 of the potential limitations of the use of a quasi-experimental study design. The quasi-experimental study is used frequently in studies of infection control and antibiotic resistance. Efforts to improve the conduct and presentation of quasi-experimental studies are urgently needed to more rigorously evaluate interventions.

The Impact of Deep Sternal Wound Infection on Long-term Survival After Coronary Artery Bypass Grafting

OBJECTIVES

To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG).

BACKGROUND

DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality.

METHODS

We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI.

RESULTS

DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 +/- 2.4% vs 50.8.6 +/- 8.5% [mean +/- SE]; p = 0.0007 between matched groups).

CONCLUSIONS

We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.

Recent developments in the prevention of surgical site infections: preoperative screening and postoperative surveillance

The purpose of this review is to cover the literature on the prevention of postsurgical infections in the period January 2002 to May 2003. Only articles that address novel insights in the prevention of infections are included in this review. The most interesting findings were observed in preoperative screening of patients for nasal carriage of Staphylococcus aureus. Eradication of Staphylococcus aureus in nasal carriers resulted in reduction of postsurgical nosocomial infections due to (endogenous) S. aureus infections. Furthermore, postoperative surveillance studies revealed insight in the incidence of surgical site infections, showed the use of risk indices and identified risk factors important for the development of postsurgical infections.

Nasal Carriage of Staphylococcus aureus As a Risk Factor for Skin and Soft Tissue Infections

Nasal carriage of Staphylococcus aureus is a major risk factor for the development of S. aureus infection, including skin and soft tissue infections and foreign body infections, such as catheter-associated bacteremia and peritonitis. In this article, we review the recent literature on S. aureus nasal carriage, including the emergence of methicillin- resistant S. aureus in the community, the pathophysiology of nasal carriage, and the epidemiology and prevention of S. aureus infections associated with nasal carriage.