Is it worth screening elective orthopaedic patients for carriage ofStaphylococcus aureus? A part-retrospective case–control study in a Scottish hospital

Abstract

BackgroundWith recent focus on methicillin-resistant Staphylococcus aureus (MRSA) screening, methicillin-susceptible S. aureus (MSSA) has been overlooked. MSSA infections are costly and debilitating in orthopaedic surgery.MethodsWe broadened MRSA screening to include MSSA for elective orthopaedic patients. Preoperative decolonisation was offered if appropriate. Elective and trauma patients were audited for staphylococcal infection during 2 6-month periods (A: January to June 2013 MRSA screening; B: January to June 2014 MRSA and MSSA screening). Trauma patients are not screened presurgery and provided a control. MSSA screening costs of a modelled cohort of 500 elective patients were offset by changes in number and costs of MSSA infections to demonstrate the change in total health service costs.FindingsTrauma patients showed similar infection rates during both periods (p=1). In period A, 4 (1.72%) and 15 (6.47%) of 232 elective patients suffered superficial and deep MSSA infections, respectively, with 6 superficial (2%) and 1 deep (0.3%) infection among 307 elective patients during period B. For any MSSA infection, risk ratios were 0.95 (95% CI 0.41 to 2.23) for trauma and 0.28 (95% CI 0.12 to 0.65) for elective patients (period B vs period A). For deep MSSA infections, risk ratios were 0.58 (95% CI 0.20 to 1.67) for trauma and 0.05 (95% CI 0.01 to 0.36) for elective patients (p=0.011). There were 29.12 fewer deep infections in the modelled cohort of 500 patients, with a cost reduction of £831 678 for 500 patients screened.ConclusionsMSSA screening for elective orthopaedic patients may reduce the risk of deep postoperative MSSA infection with associated cost-benefits.

Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques

“… 30 S. aureus screening and eradication programmes prior to elective orthopaedic surgery have a reported relative risk reduction of 66.4% (95% CI 45.8 to 87.0) for the prevention of S. aureus SSI. 18 , 30 - 34 According to economic estimates in the United States, the hospital treatment costs for an individual patient with prosthetic joint infection (PJI) range from $30 000 to $120 000. 35 - 37 Estimates in the United Kingdom for total hospital care costs per case are similar to that in the United States (between £20 000 and £100 000).…”

“… 17 A recent retrospective part cohort United Kingdom-based study among patients undergoing elective orthopaedic surgery reported a threefold reduction in MSSA -associated SSI, using a routine preoperative screening and decolonization programme. 18 In contrast to MSSA, MRSA prevalence in healthy community individuals is estimated to be < 2%. 19 Screening of patients presenting for surgery or admitted to hospital areas with strong risk factors for MRSA , such as intensive care units (ICUs), dialysis units, and elderly care areas, is widely practised in healthcare systems.…”

Prevention of fracture-related infection: a multidisciplinary care package

“…Combined screening for MRSA and MSSA has thus been suggested because a reduced risk of infection caused by S. aureus might outweigh the extra costs of additional screening [30]. Several studies provided evidence for the value of pre-operative screening for S. aureus and subsequent decolonisation in the reduction of hospital-acquired SSIs caused by this pathogen [24,31].…”

View point: gaps in the current guidelines for the prevention of Methicillin-resistant Staphylococcus aureus surgical site infections

“…aureus decolonization is daily body washes with an antiseptic for five days plus an intranasal antibiotic ointment, given three times a day. For MRSA positive patients, 2% mupirocin is often applied intranasally; for MSSA positive patients, Naseptin Nasal Cream (chlorhexidine hydrochloride 0.1%; neomycin sulfate 0.5%) can be used [ 27 ]. Eradication of the MRSA carrier state was achieved in up to 88% of healthcare workers [ 20 ].…”