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.

A more integrated approach can support multidisciplinary teams with the capacity to maximize effective and safe C&D in health care.

Objective To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures.Design Systematic review and meta-analysis. PubMed (1995PubMed ( to 2011, the Cochrane database of systematic reviews, CINAHL, Embase, and clinicaltrials.gov were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed. Data sourcesEligibility criteria Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care.Participants Patients undergoing cardiac operations or total joint replacement procedures. Results 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56).Conclusions Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.

H ealth care-associated infections, associated with antibiotic resistance, lead to considerable morbidity, mortality, and costs. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are the primary causes of these infections and are associated with worse outcomes than infections caused by antibiotic-susceptible S. aureus and Enterococcus. Although current interventions to prevent such infections focus on hand hygiene, compliance rates remain low. The use of gloves and gowns, however, may reduce the acquisition of antibiotic-susceptible and antibiotic-resistant bacteria by health care workers and decrease transmission to patients. This clusterrandomized trial was conducted to assess whether wearing gloves and gowns for all contact with intensive care unit (ICU) patients compared with the use of contract precautions only would reduce acquisition rates of MRSA and VRE infections.The study was conducted in 20 medical and surgical ICUs in 20 US hospitals during 2012. In the intervention group (10 ICUs), health care workers wore gloves and gowns for all patient contact and when entering any patient room. The control group workers (10 ICUs) wore gloves and gowns according to the Centers for Disease Control guidelines for patients with known antibioticresistant bacteria. In 2011, ICU staff collected baseline data on the primary outcome of MRSA or VRE acquisition. The ICUs were then pair matched based on baseline MRSA or VRE acquisition rates as a composite outcome. The primary outcome was acquisition of either MRSA or VRE as a composite based on results of ICU admission and discharge surveillance cultures for MRSA and VRE. Secondary outcomes were MRSA and VRE acquisition as 2 separate outcomes, frequency of health care worker visits, hand hygiene compliance, health care-associated infections, and adverse events. Analyses of all outcomes were conducted at the ICU level, followed the intention-to-treat approach, and accounted for the matched-pair design.During the baseline and study periods, 6324 and 19,856 patients were admitted to ICUs, respectively, and 20,646 and 71,595 swabs, respectively, were collected for detection of MRSA and VRE. Compliance with wearing gloves in the intervention ICUs was 86.18% (2787/3234), and compliance with gowns was 85.14% (2750/3230). In the control group, 10.52% of patients were on contact precautions, and for these patients, compliance with staff wearing gloves and gowns was 84.11% (556/661) and 81.21% (536/660), respectively. The intervention ICUs had a decrease in the primary outcome from 21.35 acquisitions per 1000 patient-days (95% confidence interval [CI], in the baseline period to 16.92 acquisitions per 1000 patientdays (95% CI, 14.09-20.28) in the study period. Control ICUs had a decrease from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20-25.49 acquisitions) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI,) in the study period. This difference in changes was not statistically significant (difference, −1....

These data from a large multicenter collaborative study confirm and extend previous observations and show a consistent relationship between the timing of AMP and SSI risk with a trend toward lower risk occurring when AMP with cephalosporins and other antibiotics with short infusion times were given within 30 minutes prior to incision.