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

Abstract

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.

Healthcare‐acquired infections: prevention strategies

“…Variation in practice continues with some advocating targeted decolonisation following screening and others favouring universal decolonisation of all high risk surgical patients. [60][61][62][63] Surgical units with high rates of MRSA should consider pre-operative screening for all patients to facilitate decolonisation and targeted surgical prophylaxis.…”

CORR Insights®: Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Hip Arthroplasty?

“…Lastly, SSI-prevention science has advanced so much in the past few decades that much of the low-hanging fruit has been plucked, and simple additional interventions are unlikely to substantially reduce the absolute number of infections. Thus, we may need to better understand how this current intervention can be included in more complex preadmission bundles that address more than one modifiable risk factor, for example smoking, uncontrolled blood glucose, malnutrition, and S aureus colonization [4,6].…”

“…In addition, Schweizer and colleagues [6] included empiric cutaneous antisepsis along with targeted S aureus decolonization and showed a significant reduction in SSIs due to S aureus but not SSIs due to any pathogen. Therefore, prospective trials evaluating a multifaceted approach addressing other modifiable risk factors will be of greatest interest to healthcare systems, payers, and ultimately patients.…”

“…For example, the inclusion of revision arthroplasties, a population recognized as a higher risk for SSIs, which improves the generalizability of the findings. In addition, infection surveillance was performed for 1 year after the operation instead of just 90 days, as seen in some recent studies [6] or even less than a week as seen in an older trial [5] which improves the strength of this study. The intervention itself was also simple and compliance was easily measured, making this a pragmatic study.…”

Does a one hour educational class improve compliance of chlorhexidine gluconate baths prior to operation?

“…CHG is a topical antiseptic used to limit the risk of SSI's and healthcare-associated infections (HAIs) by disinfecting the skin of patients before surgery. [10,11] CHG is considered an affordable option with minimal side effects. Except for rare cases of anaphylaxes, side effects are typically limited to localized skin irritations and reactions.…”