Methicillin-Resistant Staphylococcus aureus-Associated Infections following Septorhinoplasty

Abstract

A 26-year-old healthy female nurse underwent an uncomplicated open approach septorhinoplasty for nasal obstruction and aesthetic concerns. The procedure consisted of a septoplasty, spreader grafts, cephalic trim, tongue-in-groove displacement of the lower-lateral cartilages, a dome-spanning suture, medial and lateral osteotomies, and bilateral type 2 Weir excisions. As per our standard practice, a single dose of preoperative azithromycin was provided given self-reported allergies to penicillin, cephalosporins, clindamycin, and sulfabased medications. Postoperatively, the patient was instructed to apply Bacitracin ointment to her incision sites for 3 days followed by petroleum jelly for 3 days. The patient convalesced well but contacted the on-call resident on the fourth postoperative day with concerns of persistent nasal discomfort despite narcotic analgesia. The patient was asked to return to the hospital for evaluation but elected to forgo assessment until her upcoming follow-up appointment. On postoperative day 6, the patient presented to the clinic with continuing discomfort and a fever of 38°C. Examination revealed inflammation and edema at the base of the caudal septum with some slight erythema at the nasal base. A diagnosis of cellulitis was considered and ciprofloxacin was prescribed. The patient returned to the clinic the following day for reassessment. The caudal septum appeared to be more fluctuant and the area was anesthetized, then incised and explored with a sterile hemostat, resulting in egress of a small amount of pus from a moderately sized pocket between the mucoperichondrial flaps. Aerobic and anaerobic cultures were taken from this early septal abscess. Sterile iodoform gauze was then loosely packed into the cavity and the patient returned the following day for reevaluation.Cultures revealed methicillin-resistant Staphylococcus aureus (MRSA) resistant to ciprofloxacin. The inflammation of the caudal septum appeared slightly improved and the iodoform gauze was removed. Review of the patient's allergy history revealed some uncertainty regarding a reaction to sulfa. Consequently, the patient was prescribed trimethoprim/sulfamethoxazole (TMP/SMX) and topical mupirocin AbstractSeptorhinoplasty is associated with postoperative infection in less than 2% of cases, even without the use of prophylactic antibiotics. However, there is a concern that increasingly prevalent, highly virulent pathogens such as MRSA may predispose to postoperative infections. Over the past several decades, MRSA has emerged as the most important cause of antibiotic-resistant nosocomial infection. MRSA-associated infections related to nasal surgery are underreported in the literature. We present a case of MRSA-associated infection following a routine septorhinoplasty in a health care worker. We discuss the incidence of this complication and contributing risk factors. The classification of MRSAassociated infections into genotypically distinct hospital-acquired and communityacquired subtypes is reviewed, and the associated differ...

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