Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis

Schweizer, Marin L.; Perencevich, Eli N.; McDanel, Jennifer S.; Carson, J.; Formanek, Michelle B.; Hafner, Joanne; Braun, Barbara I.; Herwaldt, Loreen A.

doi:10.1136/bmj.f2743

Cited by 195 publications

(130 citation statements)

References 68 publications

(37 reference statements)

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“…Two systematic literature reviews and meta-analyses of published studies found a protective effect of mupirocin decolonization against surgical site infections (SSIs), especially among nongeneral surgery such as cardiac surgery, orthopedic surgery, and neurosurgery (38,42). (see Decolonization Prior to Surgery below for additional information) Two other meta-analyses found that decolonization with nasal mupirocin alone or in combination with topical agents such as CHG decreased the odds of S. aureus infection by approximately 60% among dialysis patients (39,44).…”

Section: Mupirocinmentioning

confidence: 99%

“…More studies have evaluated decolonization among surgical patients than among any other patient population (38,42,44). Studies have shown that decolonization can decrease the incidence of Gram-positive SSIs after some types of surgery (38,149).…”

Section: Decolonization Prior To Surgerymentioning

confidence: 99%

“…There is strong evidence that nasal and skin decolonization prior to cardiac and orthopedic surgery is effective at preventing SSIs caused by Gram-positive organisms that are susceptible to mupirocin and CHG. A meta-analysis of 17 RCTs or quasi-experimental studies that included cardiac and orthopedic surgery patients evaluated the effectiveness of preoperative decolonization (38). All but one of the studies included in the meta-analysis used mupirocin ointment for nasal decolonization, but one study used nasal CHG (150).…”

Section: Decolonization Prior To Surgerymentioning

confidence: 99%

“…The two most common methods of decolonization are application of antimicrobial ointment to the nose and of antimicrobial body washes to the skin. These have been shown to reduce infections in specific subsets of patients, such as surgical, dialysis, long-termcare, and ICU patients, although results vary depending on the pathogen and the host (26,(38)(39)(40)(41)(42)(43)(44).…”

mentioning

confidence: 99%

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Decolonization in Prevention of Health Care-Associated Infections

2016

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SUMMARYColonization with health care-associated pathogens such asStaphylococcus aureus, enterococci, Gram-negative organisms, andClostridium difficileis associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused onS. aureusdecolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent forS. aureusnasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well asCandida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

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Section: Mupirocinmentioning

confidence: 99%

Section: Decolonization Prior To Surgerymentioning

confidence: 99%

Section: Decolonization Prior To Surgerymentioning

confidence: 99%

mentioning

confidence: 99%

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Decolonization in Prevention of Health Care-Associated Infections

2016

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“…In addition, MRSA carriers act as reservoirs for the transmission of MRSA between hospitalized patients. Preoperative S. aureus screening and decolonization regimens for those undergoing selected surgeries have been advocated to decrease the infection risk in carriers (3,4). Decolonization therapy can also be a successful infection control strategy to limit MRSA transmission within hospitals (5).…”

mentioning

confidence: 99%

Mupirocin-Induced Mutations in ileS in Various Genetic Backgrounds of Methicillin-Resistant Staphylococcus aureus

et al. 2014

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Topical mupirocin is widely used for the decolonization of methicillin-resistant Staphylococcus aureus (MRSA) carriers. We evaluated the capacity of various MRSA clonotypes to develop mutations in the ileS gene associated with low-level mupirocin resistance. Twenty-four mupirocin-sensitive MRSA isolates from a variety of genotypes (determined by a multilocus variablenumber tandem-repeat assay) were selected. Mupirocin MICs were determined by Etest. The isolates were then incubated in subinhibitory concentrations of mupirocin for 7 to 14 days. Repeat MIC determinations and sequencing of the ileS gene were then performed. Doubling times of isolates exposed to mupirocin and of unexposed isolates were compared. We found that exposure to mupirocin led to rapid induction of low-level resistance (MICs of 8 to 24 g/ml) in 11 of 24 (46%) MRSA isolates. This phenomenon was observed in strains with diverse genetic backgrounds. Various mutations were detected in 18 of 24 (75%) MRSA isolates. Acquisition of mutations appeared to be a stepwise process during prolonged incubation with the drug. Among the five isolates exhibiting low-level resistance and the highest MICs, four tested sensitive after incubation in the absence of mupirocin but there was no reversion to the susceptible wild-type primary sequence. Resistance was not associated with significant fitness cost, suggesting that MRSA strains with low-level mupirocin resistance may have a selective advantage in facilities where mupirocin is commonly used. Our findings emphasize the importance of the judicious use of this topical agent and the need to closely monitor for the emergence of resistance.

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Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery

Schweizer

Chiang

Septimus

et al. 2015

JAMA

260

187

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IMPORTANCE Previous studies suggested that a bundled intervention was associated with lower rates of Staphylococcus aureus surgical site infections (SSIs) among patients having cardiac or orthopedic operations.OBJECTIVE To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk of S aureus SSIs in patients undergoing cardiac operations or hip or knee arthroplasties. DESIGN, SETTING, AND PARTICIPANTS Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014).INTERVENTIONS Patients whose preoperative nares screens were positive for methicillin-resistant S aureus (MRSA) or methicillin-susceptible S aureus (MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. MAIN OUTCOMES AND MEASURESThe primary outcome was complex (deep incisional or organ space) S aureus SSIs. Monthly SSI counts were analyzed using Poisson regression analysis.RESULTS After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complex S aureus SSIs occurred after 28 218 operations during the preintervention period and 29 occurred after 14 316 operations during the intervention period (mean rate per 10 000 operations, 36 for preintervention period vs 21 for intervention period, difference, −15 [95% CI, −35 to −2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complex S aureus SSIs decreased for hip or knee arthroplasties (difference per 10 000 operations, −17 [95% CI, −39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10 000 operations, −6 [95% CI, −48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]). CONCLUSIONS AND RELEVANCEIn this multicenter study, a bundle comprising S aureus screening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complex S aureus SSIs.

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Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis

Cited by 195 publications

References 68 publications

Decolonization in Prevention of Health Care-Associated Infections

Decolonization in Prevention of Health Care-Associated Infections

Mupirocin-Induced Mutations in ileS in Various Genetic Backgrounds of Methicillin-Resistant Staphylococcus aureus

Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery

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