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Smith M, Crnich C, Donskey C, Evans CT, Evans M, Goto M, Guerrero B, Gupta K, Harris A, Hicks N, Khader K, Kralovic S, McKinley L, Rubin M, Safdar N, Schweizer ML, Tovar S, Wilson G, Zabarsky T, Perencevich EN. Research agenda for transmission prevention within the Veterans Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-10. [PMID: 38600795 DOI: 10.1017/ice.2024.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthew Smith
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Chris Crnich
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Curtis Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Martin Evans
- MRSA/MDRO Division, VHA National Infectious Diseases Service, Patient Care Services, VA Central Office and the Lexington VA Health Care System, Lexington, KY, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bernardino Guerrero
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Kalpana Gupta
- VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Anthony Harris
- Department of Epidemiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie Hicks
- National Infectious Diseases Service, Specialty Care Services, Veterans Health Administration, US Department of Veterans Affairs, Washington, DC, USA
| | - Karim Khader
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephen Kralovic
- Veterans Health Administration National Infectious Diseases Service, Washington, DC, USA
- Cincinnati VA Medical Center and University of Cincinnati, Cincinnati, OH, USA
| | - Linda McKinley
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Michael Rubin
- DEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nasia Safdar
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
| | - Marin L Schweizer
- William. S. Middleton Memorial VA Hospital, Madison, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, and William S. Middleton Hospital, Madison, WI, USA
| | - Suzanne Tovar
- National Infectious Diseases Service (NIDS), Veterans Affairs Central Office, Washington, DC, USA
| | - Geneva Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines Jr. Veterans Affairs Hospital, Hines, IL, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trina Zabarsky
- Environmental Programs Service (EPS), Veterans Affairs Central Office, Washington, DC, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Piewngam P, Otto M. Staphylococcus aureus colonisation and strategies for decolonisation. THE LANCET. MICROBE 2024:S2666-5247(24)00040-5. [PMID: 38518792 DOI: 10.1016/s2666-5247(24)00040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/24/2024]
Abstract
Staphylococcus aureus is a leading cause of death by infectious diseases worldwide. Treatment of S aureus infections is difficult due to widespread antibiotic resistance, necessitating alternative approaches and measures for prevention of infection. Because S aureus infections commonly arise from asymptomatic colonisation, decolonisation is considered a key approach for their prevention. Current decolonisation procedures include antibiotic-based and antiseptic-based eradication of S aureus from the nose and skin. However, despite the widespread implementation and partial success of such measures, S aureus infection rates remain worrisome, and resistance to decolonisation agents is on the rise. In this Review we outline the epidemiology and mechanisms of S aureus colonisation, describe how colonisation underlies infection, and discuss current and novel approaches for S aureus decolonisation, with a focus on the latest findings on probiotic strategies and the intestinal S aureus colonisation site.
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Affiliation(s)
- Pipat Piewngam
- Pathogen Molecular Genetics Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA
| | - Michael Otto
- Pathogen Molecular Genetics Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA.
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Vierra M, Rouhani Ravari M, Soleymani Sardoo F, Shogan BD. Tailored Pre-Operative Antibiotic Prophylaxis to Prevent Post-Operative Surgical Site Infections in General Surgery. Antibiotics (Basel) 2024; 13:99. [PMID: 38275328 PMCID: PMC10812803 DOI: 10.3390/antibiotics13010099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
The average American today undergoes three inpatient and two outpatient surgical procedures during one's life, each of which carries with it a risk of post-operative infection. It has long been known that post-operative infections cause significant morbidity in the immediate peri-operative period, but recent evidence suggests that they can have long-term consequences as well, increasing a patient's risk of infectious complications in unrelated surgeries performed months or even years later. While there are several theories on the origin of this association, including bacterial colonization of a post-operative infectious wound site, antimicrobial resistance from curative courses of antibiotics, subclinical immunosuppression, or the creation of an inflammatory "pathobiome" following an infectious insult, it is ultimately still unclear why patients who experience a single post-operative infection seem to be at a significantly higher risk of experiencing subsequent ones. Regardless, this association has significant implications for the routine use of pre-operative antibiotic prophylaxis. Indeed, while the prescription of antibiotics pre-operatively has dramatically reduced the rate of post-operative infections, the chosen prophylaxis regimens are typically standardized according to national guidelines, are facing increasing antimicrobial resistance patterns, and have been unable to reduce the risk of post-operative infection to acceptably low levels for certain surgeries. As a result, some clinicians have speculated that tailoring pre-operative antibiotic prophylaxis according to a patient's prior infectious and operative history could improve efficacy and further reduce the rate of post-operative infections. The purpose of this review is to describe the evidence for the link between multiple post-operative infections and explore the efficacy of individualized pre-operative prophylaxis.
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Affiliation(s)
- Mason Vierra
- Pritzker School of Medicine, The University of Chicago, Chicago, IL 60637, USA;
| | - Mohsen Rouhani Ravari
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
| | - Fatemeh Soleymani Sardoo
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
| | - Benjamin D. Shogan
- Department of Surgery, The University of Chicago Medicine, Chicago, IL 60637, USA; (M.R.R.); (F.S.S.)
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Asai S, Takahashi N, Kishimoto K, Suzuki M, Ohashi Y, Terabe K, Kojima T, Imagama S. Increased prevalence of Staphylococcus aureus nasal carriage in rheumatoid arthritis patients with moderate/high disease activity. J Orthop Sci 2023; 28:1400-1406. [PMID: 36210264 DOI: 10.1016/j.jos.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/27/2022] [Accepted: 09/19/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Staphylococcus aureus (S. aureus) nasal carriage is a well-known risk factor for surgical site infection (SSI) after total joint arthroplasty. This study aimed to compare the prevalence of S. aureus nasal carriage between patients with osteoarthritis (OA), a degenerative joint disease, and those with rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease, who underwent total joint arthroplasty, and to investigate the influence of RA disease activity on nasal carriage rate. METHODS This retrospective study targeted 508 OA and 107 RA patients who underwent S. aureus nasal screening prior to primary total knee and/or hip arthroplasty. RA patients were divided into two groups based on disease activity: the remission/low disease activity (REM/LDA) group and the moderate/high disease activity (MDA/HDA) group. Factors associated with S. aureus nasal carriage were assessed with multivariate logistic regression models. RESULTS Of all 615 patients, 155 (25%) carried S. aureus in their nares. Compared to OA patients, RA patients had a significantly higher rate of S. aureus nasal carriage (24% vs. 33%, p = 0.049). Compared to the REM/LDA group (n = 39), the MDA/HDA group (n = 58) had a significantly higher rate of S. aureus nasal carriage (21% vs. 41%, p = 0.032). Multivariate analysis revealed that the MDA/HDA group, but not the REM/LDA group, had a significantly higher odds of S. aureus nasal carriage compared to the OA group (odds ratio: 2.76, 95% confidence interval: 1.07-7.12). CONCLUSION Preoperative nasal screening for S. aureus is beneficial, especially in RA patients with moderate/high disease activity.
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Affiliation(s)
- Shuji Asai
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.
| | - Nobunori Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenji Kishimoto
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mochihito Suzuki
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yoshifumi Ohashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kenya Terabe
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Smith M, Herwaldt L. Nasal decolonization: What antimicrobials and antiseptics are most effective before surgery and in the ICU. Am J Infect Control 2023; 51:A64-A71. [PMID: 37890955 DOI: 10.1016/j.ajic.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Staphylococcus aureus colonization is a key risk factor for S. aureus infections in surgical patients and in hospitalized patients. Many studies have assessed various decolonization agents, protocols, and settings. This review summarizes key findings about nasal decolonization for 2 different patient populations: patients undergoing surgery and patients hospitalized in intensive care units. METHODS We reviewed major studies related to decolonization of patients colonized with S. aureus and who were either undergoing surgical procedures or were hospitalized in intensive care units. We focused on recent studies, particularly randomized controlled trials and robust quasi-experimental trials. We also reviewed select non-randomized trials when more rigorous trials were limited. DISCUSSION/CONCLUSIONS Mupirocin is the best-studied agent for decolonization. Its use reduces the risk of surgical site infection following orthopedic surgery (strongest data) and cardiac surgery. Mupirocin decolonization also reduces the incidence of S. aureus clinical cultures in the intensive care unit. Povidone-iodine is less well-studied. Current data suggest that it decreases the risk of surgical site infections after orthopedic surgical procedures. In contrast, povidone-iodine is less effective than mupirocin for reducing the incidence of S aureus clinical cultures in the intensive care unit. Both mupirocin and povidone-iodine have important limitations, highlighting the need for future decolonization research.
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Affiliation(s)
- Matthew Smith
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA.
| | - Loreen Herwaldt
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
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Imam MS, Abdel‐Sattar RM, Alqarni F, Aljumayi SYS, Altukhais I, Altukhays AS, Abdelrahim MEA. Prevalence of surgical site wound infection after spine surgery in nasal colonization of methicillin-resistant Staphylococcus aureus: A meta-analysis. Int Wound J 2023; 21:e14470. [PMID: 37909167 PMCID: PMC10898389 DOI: 10.1111/iwj.14470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023] Open
Abstract
The purpose of the meta-analysis was to evaluate and compare the prevalence of surgical site infection (SSI) after spine surgery (SS) in nasal colonization of methicillin-resistant Staphylococcus aureus (MRSA). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random- or fixed-effect models. For the current meta-analysis, 14 examinations spanning from 2014 to 2022 were included, encompassing 18 410 people who were tested for nasal colonization after SS. MRSA-positive had a significantly higher SSI (OR, 3.65; 95% CI, 2.48-5.37, p < 0.001) compared with MRSA-negative in SS subjects. However, no significant difference was found between methicillin-susceptible Staphylococcus aureus and Staphylococcus aureus negative (OR, 0.94; 95% CI, 0.32-2.79, p = 0.91), and Staphylococcus aureus positive and negative (OR, 2.13; 95% CI, 0.26-17.41, p = 0.48) in SS subjects. The examined data revealed that MRSA colonization had a significant effect on SSI; however, methicillin-susceptible Staphylococcus aureus and Staphylococcus aureus had no significant effect on SSI in SS subjects. However, given that some comparisons included a small number of chosen studies, attention should be given to their values.
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Affiliation(s)
- Mohamed S. Imam
- Pharmacy Practice Department, College of PharmacyShaqra UniversityShaqraSaudi Arabia
- Clinical Pharmacy Department, National Cancer InstituteCairo UniversityCairoEgypt
| | - Randa M. Abdel‐Sattar
- Biomedical Sciences Department, College of PharmacyShaqra UniversityShaqraSaudi Arabia
| | - Faisal Alqarni
- Department of PharmacySecurity Forces HospitalRiyadhSaudi Arabia
| | - Saad Yousef S. Aljumayi
- Department of PharmacyMedical Center at the Facilities Security Forces Command, Medical ServicesRiyadhSaudi Arabia
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Karapetyan K, Mei S, Choudhury A, Cottreau J. Overview of Antibiotic Prophylaxis in Orthopaedic and Cardiac Procedures. Orthop Nurs 2023; 42:312-316. [PMID: 37708530 DOI: 10.1097/nor.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Antibiotic prophylaxis (AP) in surgical procedures is commonly used to prevent infections that may occur after operations. There are multiple factors that can contribute to increased risk of postsurgical complications that include prolonged hospitalization, reoperation, and readmissions. One of the strategies of decreasing the risk of bacterial contamination and developing infections is preprocedural antibiotic administration. When selecting an appropriate antibiotic, it is important to take into account surgery type and patient's characteristics which would also impact timing of administration and prophylaxis duration. Although surgical AP is significant for avoiding bacterial complications, it is also associated with some drawbacks such as increased antibiotic resistance and development of adverse reactions. Therefore, it is important to assess risks and benefits and select the most appropriate antibiotic regimen before initiating AP.
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Affiliation(s)
- Kristina Karapetyan
- Kristina Karapetyan, PharmD, PGY-2 Ambulatory Care Pharmacy Resident, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Sally Mei, PharmD, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Aeman Choudhury, PharmD, BCACP, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Jessica Cottreau, PharmD, BCPS, BCIDP, Chair and Associate Professor, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Sally Mei
- Kristina Karapetyan, PharmD, PGY-2 Ambulatory Care Pharmacy Resident, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Sally Mei, PharmD, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Aeman Choudhury, PharmD, BCACP, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Jessica Cottreau, PharmD, BCPS, BCIDP, Chair and Associate Professor, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Aeman Choudhury
- Kristina Karapetyan, PharmD, PGY-2 Ambulatory Care Pharmacy Resident, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Sally Mei, PharmD, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Aeman Choudhury, PharmD, BCACP, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Jessica Cottreau, PharmD, BCPS, BCIDP, Chair and Associate Professor, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Jessica Cottreau
- Kristina Karapetyan, PharmD, PGY-2 Ambulatory Care Pharmacy Resident, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Sally Mei, PharmD, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Aeman Choudhury, PharmD, BCACP, Clinical Pharmacy Practitioner, Captain James A. Lovell Federal Health Care Center, North Chicago, IL
- Jessica Cottreau, PharmD, BCPS, BCIDP, Chair and Associate Professor, Department of Pharmacy Practice, Rosalind Franklin University of Medicine and Science, North Chicago, IL
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Suzuki H, Perencevich EN, Hockett Sherlock S, Clore GS, O'Shea AMJ, Forrest GN, Pfeiffer CD, Safdar N, Crnich C, Gupta K, Strymish J, Lira GB, Bradley S, Cadena-Zuluaga J, Rubin M, Bittner M, Morgan D, DeVries A, Miell K, Alexander B, Schweizer ML. Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals. JAMA Netw Open 2023; 6:e2324516. [PMID: 37471087 DOI: 10.1001/jamanetworkopen.2023.24516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Importance While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. Objective To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. Design, Setting, and Participants This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Interventions Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. Main Outcomes and Measures The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Results Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Conclusions and Relevance Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.
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Affiliation(s)
- Hiroyuki Suzuki
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli N Perencevich
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Stacey Hockett Sherlock
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Gosia S Clore
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Amy M J O'Shea
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Graeme N Forrest
- Division of Infectious Disease, Rush University Medical Center, Chicago, Illinois
| | - Christopher D Pfeiffer
- Infectious Diseases Section, VA Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, OHSU, Portland, Oregon
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Christopher Crnich
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Kalpana Gupta
- Division of Infectious Diseases, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Judith Strymish
- Division of Infectious Diseases, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Gio Baracco Lira
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida
- Hospital Epidemiology and Occupational Health Service, Miami VA Healthcare System, Miami, Florida
| | - Suzanne Bradley
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jose Cadena-Zuluaga
- South Texas Veterans Health Care System, San Antonio
- Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Michael Rubin
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Marvin Bittner
- Nebraska-Western Iowa Veterans Affairs Health Care System, Omaha, Nebraska
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Daniel Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Health Care System, Baltimore
| | - Aaron DeVries
- Minneapolis VA Medical Center, Minneapolis, Minnesota
| | - Kelly Miell
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Bruce Alexander
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Marin L Schweizer
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1039-1067. [PMID: 37381690 PMCID: PMC10369222 DOI: 10.1017/ice.2023.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023]
Abstract
Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Kyle J. Popovich
- Department of Internal Medicine, RUSH Medical College, Chicago, Illinois
| | - Kathy Aureden
- Infection Prevention, Advocate Aurora Health, Downers Grove, Illinois
| | - D. Cal Ham
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony D. Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda J. Hessels
- Columbia School of Nursing, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Moody
- Infection Prevention, HCA Healthcare, Nashville, Tennessee
| | - Deborah Yokoe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
- Transplant Infectious Diseases, UCSF Medical Center, San Francisco, California
| | - David P. Calfee
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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Mizusawa M, Carroll KC. Recent updates in the development of molecular assays for the rapid identification and susceptibility testing of MRSA. Expert Rev Mol Diagn 2023; 23:679-699. [PMID: 37419696 DOI: 10.1080/14737159.2023.2234823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/22/2023] [Accepted: 07/06/2023] [Indexed: 07/09/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of healthcare- and community-associated infections. Nasal carriage of MRSA is a risk factor for subsequent MRSA infections. Increased morbidity and mortality are associated with MRSA infections and screening and diagnostic tests for MRSA play an important role in clinical management. AREAS COVERED A literature search was conducted in PubMed and supplemented by citation searching. In this article, we provide a comprehensive review of molecular-based methods for MRSA screening and diagnostic tests including individual nucleic acid detection assays, syndromic panels, and sequencing technologies with a focus on their analytical performance. EXPERT OPINION Molecular based-assays for the detection of MRSA have improved in terms of accuracy and availability. Rapid turnaround enables earlier contact isolation and decolonization for MRSA. The availability of syndromic panel tests that include MRSA as a target has expanded from positive blood cultures to pneumonia and osteoarticular infections. Sequencing technologies allow detailed characterizations of novel methicillin-resistance mechanisms that can be incorporated into future assays. Next generation sequencing is capable of diagnosing MRSA infections that cannot be identified by conventional methods and metagenomic next-generation sequencing (mNGS) assays will likely move closer to implementation as front-line diagnostics in the near future.
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Affiliation(s)
- Masako Mizusawa
- Monmouth Medical Center, Rutgers University Robert Wood Johnson Medical School, Long Branch, NJ, USA
| | - Karen C Carroll
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Viola GM, Szvalb AD, Malek AE, Chaftari AM, Hachem R, Raad II. Prevention of device-related infections in patients with cancer: Current practice and future horizons. CA Cancer J Clin 2023; 73:147-163. [PMID: 36149820 PMCID: PMC9992006 DOI: 10.3322/caac.21756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.
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Affiliation(s)
- George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandre E Malek
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
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Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
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Wilson E, Marra AR, Ward M, Chapin L, Boulden S, Ryken TC, Jones LC, Herwaldt LA. Patients' experiences and compliance with preoperative screening and decolonization. Am J Infect Control 2023; 51:78-82. [PMID: 35339622 DOI: 10.1016/j.ajic.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND To improve adherence with pre-surgical screening for Staphylococcus aureus nasal carriage and decolonization, we need more information about patients' experiences with these protocols. METHODS We surveyed patients undergoing orthopedic, neurosurgical, or cardiac operations at Johns Hopkins Hospitals (JHH), the University of Iowa Hospitals and Clinics (UIHC) at MercyOne Northeast Iowa Neurosurgery (MONIN) to assess patients' experiences with decolonization protocols. RESULTS Five hundred thirty-four patients responded. Respondents at JHH were significantly more likely than those at the UIHC to report using mupirocin and were significantly more likely than those at the UIHC and MONIN to feel they received adequate information about surgical site infection (SSI) prevention and decolonization. Respondents at JHH were the least likely to not worry about SSI and they were more willing to do anything they could to prevent SSI. Few patients reported barriers to adherence and side effects of mupirocin or chlorhexidine. CONCLUSION Respondents did not report either major side effects or barriers to adherence. Patients varied in their level of concern about SSI, their willingness to invest effort in preventing SSI, and their assessments of preoperative information. To improve patients' adherence, clinicians and hospitals should assess their patients' needs and desires and tailor their preoperative processes, education, and prophylaxis accordingly.
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Affiliation(s)
- Ethan Wilson
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA
| | - Alexandre R Marra
- University of Iowa Hospitals & Clinics, Iowa City, IA, USA; Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Melissa Ward
- University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA
| | - Laura Chapin
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA
| | | | - Timothy C Ryken
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA; Dartmouth-Hitchcock Medical Center, Department of Neurosurgery, Lebanon, NH, USA
| | - Lynne C Jones
- Johns Hopkins School of Medicine, Department of Orthopaedic Surgery, Baltimore, MD, USA
| | - Loreen A Herwaldt
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA.
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Sun J, Qian D, Zhou R, Tang R, Guan L, Ye Y, Pu Y, Yu M. Effects of preoperative Staphylococcus aureus screening and targeted decolonization bundle protocols in cardiac surgery: a nine-year review of a regional cardiovascular center in China. J Thorac Dis 2022; 14:4741-4750. [PMID: 36647471 PMCID: PMC9840028 DOI: 10.21037/jtd-22-591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
Background Nosocomial infection (NI) prolongs hospital stay and heightens mortality among patients who underwent cardiac surgery. We constructed a retrospective study to explore the prevalence of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (SA/MRSA) nasal colonization, as well as the effects of SA/MRSA decolonization bundle measures on SA/MRSA-related infection among Chinese cardiac patients. Methods After reviewing the medical records, we divided cardiovascular surgery patients treated at our central campus into two groups: the baseline group (treated between January 2012 and December 2013) and the intervention group (treated between May 2014 and December 2020). Intervention measures consisted of preoperative nasal screening and targeted decolonization bundle therapy. The medical records of patients at our southern campus (treated between January 2017 and December 2020) were collected as an additional control group, since we did not implement SA intervention measures at this location. The incidences of SA/MRSA-related NI were then compared between the groups. Results There were 794 patients in the baseline group and 2,826 in the intervention group. A total of 131 (4.6%) patients had SA nasal colonization, and among them, 33 patients (1.2%) were MRSA colonized. SA/MRSA was cleared in approximately 95% of the carriers. The total level of SA-related infection was significantly lower in the intervention group compared to the baseline group [0.354% vs. 1.133%, respectively; P=0.021; risk ratio (RR): 0.312; 95% confidence interval (CI): 0.127-0.766]. The incidence of MRSA-related infection followed the same trend (0.212% vs. 0.756%, respectively; P=0.030; RR: 0.281; 95% CI: 0.091-0.860). When compared to the southern campus, SA intervention measures at the central campus resulted in a significant reduction in total SA-related infection (1.132% vs. 0.284%, respectively; P=0.035; RR: 0.251; 95% CI: 0.077-0.820). Conclusions The prevalence of SA/MRSA colonization is relatively low among Chinese patients who received cardiovascular surgery. Targeted decolonization bundle therapy was associated with cleared colonization and reduced incidence of SA/MRSA-related infection.
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Affiliation(s)
- Jufang Sun
- Department of Nursing, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dewei Qian
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ren Zhou
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Tang
- Microbiological laboratory, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lichun Guan
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yizhou Ye
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Pu
- Department of Nursing, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Yu
- Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Zukowska A, Zukowski M. Surgical Site Infection in Cardiac Surgery. J Clin Med 2022; 11:jcm11236991. [PMID: 36498567 PMCID: PMC9738257 DOI: 10.3390/jcm11236991] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.
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Affiliation(s)
- Agnieszka Zukowska
- Department of Infection Control, Regional Hospital Stargard, 73-110 Stargard, Poland
| | - Maciej Zukowski
- Department of Anesthesiology, Intensive Care and Acute Intoxication, Pomeranian Medical University, 70-204 Szczecin, Poland
- Correspondence: ; Tel.: +48-504-451-924
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Corneci D, Torsin LI, Filimon CR, Tănase NV, Moisă E, Negoiță SI. Individualized surgical antibiotic prophylaxis – why, when, and how? ROMANIAN JOURNAL OF MILITARY MEDICINE 2022. [DOI: 10.55453/rjmm.2022.125.4.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
"Surgical site infections (SSI) greatly concern clinicians, as they are associated with significant morbidity and mortality, prolonged hospitalization, and costs. Antibiotic prophylaxis plays a pivotal role among the procedures that are usually employed for the prevention of surgical-related infections. This narrative review aims to cover some of the particular situations when the clinician might consider individualizing antibiotic prophylaxis for a patient. With the rising incidence of multi-drug resistant bacteria carriage among not only hospitalized or institutionalized patients but also patients from the community, there might be a tendency to use extended-spectrum antibiotics for longer periods for surgical infection prevention. However, the inappropriate use of antibiotics increases the selection pressure, thus favoring the spreading of resistant bacteria. Moreover, specific patient characteristics or pathologies might need to be considered to customize the type, dose, or length of administration of an antibiotic as surgical prophylaxis. Using prosthetic material or prolonged surgeries with large fluid shifts are other situations when individualized antibiotic prophylaxis might be thought of. Keeping in mind that it is of utmost importance that everyone adheres to the current guidelines for surgical antibiotic prophylaxis, customization of local protocols according to well-thought-out strategies might prove beneficial in SSI prevention."
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Bröckelmann N, Stadelmaier J, Harms L, Kubiak C, Beyerbach J, Wolkewitz M, Meerpohl JJ, Schwingshackl L. An empirical evaluation of the impact scenario of pooling bodies of evidence from randomized controlled trials and cohort studies in medical research. BMC Med 2022; 20:355. [PMID: 36274131 PMCID: PMC9590141 DOI: 10.1186/s12916-022-02559-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/09/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess treatment effects of medical interventions. We aimed to hypothetically pool bodies of evidence (BoE) from RCTs with matched BoE from cohort studies included in the same systematic review. METHODS BoE derived from systematic reviews of RCTs and cohort studies published in the 13 medical journals with the highest impact factor were considered. We re-analyzed effect estimates of the included systematic reviews by pooling BoE from RCTs with BoE from cohort studies using random and common effects models. We evaluated statistical heterogeneity, 95% prediction intervals, weight of BoE from RCTs to the pooled estimate, and whether integration of BoE from cohort studies modified the conclusion from BoE of RCTs. RESULTS Overall, 118 BoE-pairs based on 653 RCTs and 804 cohort studies were pooled. By pooling BoE from RCTs and cohort studies with a random effects model, for 61 (51.7%) out of 118 BoE-pairs, the 95% confidence interval (CI) excludes no effect. By pooling BoE from RCTs and cohort studies, the median I2 was 48%, and the median contributed percentage weight of RCTs to the pooled estimates was 40%. The direction of effect between BoE from RCTs and pooled effect estimates was mainly concordant (79.7%). The integration of BoE from cohort studies modified the conclusion (by examining the 95% CI) from BoE of RCTs in 32 (27%) of the 118 BoE-pairs, but the direction of effect was mainly concordant (88%). CONCLUSIONS Our findings provide insights for the potential impact of pooling both BoE in systematic reviews. In medical research, it is often important to rely on both evidence of RCTs and cohort studies to get a whole picture of an investigated intervention-disease association. A decision for or against pooling different study designs should also always take into account, for example, PI/ECO similarity, risk of bias, coherence of effect estimates, and also the trustworthiness of the evidence. Overall, there is a need for more research on the influence of those issues on potential pooling.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Stadelmaier
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Jörg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Labrecque S, Shah S, Fergus D, Parry MF. Mupirocin Susceptibility of Staphylococci 2022: Is it time for a change in MRSA decolonization protocols? Am J Infect Control 2022:S0196-6553(22)00657-5. [PMID: 36116681 DOI: 10.1016/j.ajic.2022.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nasal decolonization with mupirocin has been a common strategy for the prevention of surgical site infections (SSIs) and recurrent skin and soft tissue infections due to Staphylococcus aureus (SA). We recently noted an increase in SSIs due to SA, including a case of post-operative mupirocin-resistant methicillin-resistant SA (MRSA) infection despite attempted preoperative decolonization with mupirocin. We therefore evaluated the mupirocin susceptibility of SA at our hospital to determine the optimal regimen for decolonization. METHODS SA isolates were recovered from clinical and screening samples received in the microbiology laboratory. Mupirocin susceptibility was determined using e-tests and isolates were categorized as susceptible or resistant using a breakpoint MIC value of 4mcg/ml. RESULTS 223 unique SA isolates from 218 patients were tested. Twenty-four SA isolates (10.8%) were resistant to mupirocin (20 MRSA and 4 methicillin-sensitive SA [MSSA]). MRSA strains were more likely to be resistant to mupirocin than MSSA strains (22.5% versus 3.0%, p<0.001). CONCLUSIONS The emergence of drug resistance makes the policy of decolonization with nasal mupirocin a suboptimal strategy for the prevention of MRSA infections. In our study, less than 80% of MRSA strains were mupirocin susceptible. In patients colonized with MRSA at high risk for infection (e.g., total joint replacement), other regimens such as intranasal povidone iodine may be preferrable to mupirocin for patient decolonization.
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Affiliation(s)
- Sophie Labrecque
- Departments of Microbiology and Infectious Diseases, Stamford Health, Stamford, CT
| | - Sonia Shah
- Departments of Microbiology and Infectious Diseases, Stamford Health, Stamford, CT
| | - Diedre Fergus
- Departments of Microbiology and Infectious Diseases, Stamford Health, Stamford, CT
| | - Michael F Parry
- Departments of Microbiology and Infectious Diseases, Stamford Health, Stamford, CT; Division of Infectious Diseases, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
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Pre-surgical Nasal Decolonization of Staphylococcus aureus: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2022; 22:1-165. [PMID: 36160757 PMCID: PMC9470215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Staphylococcus aureus (S. aureus) is the most common cause of surgical site infections, and the nose is the most common site for S. aureus colonization. Pre-surgical (in the days prior to surgery) nasal decolonization of S. aureus may reduce the bacterial load and prevent the organisms from being transferred to the surgical site, thus reducing the risk of surgical site infection. We conducted a health technology assessment of nasal decolonization of S. aureus (including methicillin-susceptible and methicillin-resistant strains) with or without topical antiseptic body wash to prevent surgical site infection in patients undergoing scheduled surgery, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding nasal decolonization of S. aureus, and patient preferences and values. METHODS We performed a systematic literature search of the clinical evidence to retrieve systematic reviews and selected and reported results from one review that was recent, of high quality, and relevant to our research question. We complemented the chosen systematic review with a literature search to identify randomized controlled trials published since the systematic review was published in 2019. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review and the Cochrane risk-of-bias tool for randomized controlled trials to assess the risk of bias of each included primary study. We assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted both cost-effectiveness and cost-utility analyses using a decision-tree model with a 1-year time horizon from the perspective of Ontario's Ministry of Health. We also analyzed the budget impact of publicly funding nasal decolonization of S. aureus in pre-surgical patients in Ontario. To contextualize the potential value of nasal decolonization, we spoke with people who had recently undergone surgery, some of whom had received nasal decolonization, and one family member of a person who had recently had surgery. We also engaged participants through an online survey. RESULTS We included one systematic review and three randomized controlled trials in the clinical evidence review. In universal decolonization, compared with placebo or no intervention, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients undergoing orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of S. aureus carrier status (GRADE: Moderate to Very low). Compared with placebo, nasal mupirocin alone may result in little to no difference in the incidence of overall and S. aureus-related surgical site infections in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, general, oncologic, gynaecologic, or neurologic surgery (GRADE: Moderate to Very low). In targeted decolonization, compared with placebo, nasal mupirocin combined with chlorhexidine body wash lowers the incidence of S. aureus-related surgical site infection (risk ratio: 0.32 [95% confidence interval: 0.16-0.62]) in pre-surgical patients who are S. aureus carriers undergoing cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery (GRADE: High). Compared with no intervention, nasal mupirocin combined with chlorhexidine body wash in pre-surgical patients who are not S. aureus carriers undergoing orthopaedic surgery may have little to no effect on overall surgical site infection, but the evidence is very uncertain (GRADE: Very low). Most included studies did not separate methicillin-susceptible and methicillin-resistant strains of S. aureus. No significant antimicrobial resistance was identified in the evidence reviewed; however, the existing literature was not adequately powered and did not have sufficient follow-up time to evaluate antimicrobial resistance.Our economic evaluation found that universal nasal decolonization using mupirocin combined with chlorhexidine body wash is less costly and more effective than both targeted and no nasal decolonization. Compared with no nasal decolonization treatment, universal and targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would prevent 32 and 22 S. aureus-related surgical site infections, respectively, per 10,000 patients. Universal nasal decolonization would lead to cost savings, whereas targeted nasal decolonization would increase the overall cost for the health care system since patients must first be screened for S. aureus carrier status before receiving nasal decolonization with mupirocin. The annual budget impact of publicly funding universal nasal decolonization in Ontario over the next 5 years ranges from a savings of $2.98 million in year 1 to a savings of $15.09 million in year 5. The annual budget impact of publicly funding targeted nasal decolonization ranges from an additional cost of $0.08 million in year 1 to an additional cost of $0.39 million in year 5.Our interview and survey respondents felt strongly about the value of preventing surgical site infections, and most favoured a universal approach. CONCLUSIONS Based on the best evidence available, decolonization of S. aureus using nasal mupirocin combined with chlorhexidine body wash prior to cardiothoracic, vascular, orthopaedic, gastrointestinal, or general surgery lowers the incidence of surgical site infection caused by S. aureus in patients who are S. aureus carriers (including methicillin-susceptible and methicillin-resistant strains) (i.e., targeted decolonization). However, nasal mupirocin alone may result in little to no difference in overall surgical site infections and S. aureus-related surgical site infections in pre-surgical patients prior to orthopaedic, cardiothoracic, general, oncologic, gynaecologic, neurologic, or abdominal digestive surgeries, regardless of their S. aureus carrier status (i.e., universal decolonization). No significant antimicrobial resistance was identified in the evidence reviewed.Compared with no nasal decolonization treatment, universal nasal decolonization with mupirocin combined with chlorhexidine body wash may reduce S. aureus-related surgical site infections and lead to cost savings. Targeted nasal decolonization with mupirocin combined with chlorhexidine body wash may also reduce S. aureus-related surgical site infections but increase the overall cost of treatment for the health care system. We estimate that publicly funding universal nasal decolonization using mupirocin combined with chlorhexidine body wash would result in a total cost savings of $45.08 million over the next 5 years, whereas publicly funding targeted nasal decolonization using mupirocin combined with chlorhexidine body wash would incur an additional cost of $1.17 million over the next 5 years.People undergoing surgery value treatments aimed at preventing surgical site infections.
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21
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Edmiston CE, Leaper DJ. Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review. Surg Infect (Larchmt) 2022; 23:645-655. [PMID: 35925775 DOI: 10.1089/sur.2022.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.
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Affiliation(s)
- Charles E Edmiston
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin USA
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22
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Raslan R, Doll M, Albert H, Shah H, Bohl J, Cooper K, Stevens MP, Bearman G. Staphylococcal decolonization to prevent surgical site infection: Is there a role in colorectal surgery? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e116. [PMID: 36483388 PMCID: PMC9726530 DOI: 10.1017/ash.2022.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs). DESIGN Retrospective observational study. SETTING Tertiary-care, academic medical center. PATIENTS Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded. METHODS Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service. RESULTS In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04). CONCLUSIONS Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.
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Affiliation(s)
- Rasha Raslan
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Michelle Doll
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Heather Albert
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Hirsh Shah
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Jaime Bohl
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Kaila Cooper
- Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Michael P. Stevens
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Gonzalo Bearman
- Virginia Commonwealth University Medical Center, Richmond, Virginia
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
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23
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Bröckelmann N, Balduzzi S, Harms L, Beyerbach J, Petropoulou M, Kubiak C, Wolkewitz M, Meerpohl JJ, Schwingshackl L. Evaluating agreement between bodies of evidence from randomized controlled trials and cohort studies in medical research: a meta-epidemiological study. BMC Med 2022; 20:174. [PMID: 35538478 PMCID: PMC9092682 DOI: 10.1186/s12916-022-02369-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess the treatment effects of medical interventions. To evaluate the agreement of effect estimates between bodies of evidence (BoE) from randomized controlled trials (RCTs) and cohort studies and to identify factors associated with disagreement. METHODS Systematic reviews were published in the 13 medical journals with the highest impact factor identified through a MEDLINE search. BoE-pairs from RCTs and cohort studies with the same medical research question were included. We rated the similarity of PI/ECO (Population, Intervention/Exposure, Comparison, Outcome) between BoE from RCTs and cohort studies. The agreement of effect estimates across BoE was analyzed by pooling ratio of ratios (RoR) for binary outcomes and difference of mean differences for continuous outcomes. We performed subgroup analyses to explore factors associated with disagreements. RESULTS One hundred twenty-nine BoE pairs from 64 systematic reviews were included. PI/ECO-similarity degree was moderate: two BoE pairs were rated as "more or less identical"; 90 were rated as "similar but not identical" and 37 as only "broadly similar". For binary outcomes, the pooled RoR was 1.04 (95% CI 0.97-1.11) with considerable statistical heterogeneity. For continuous outcomes, differences were small. In subgroup analyses, degree of PI/ECO-similarity, type of intervention, and type of outcome, the pooled RoR indicated that on average, differences between both BoE were small. Subgroup analysis by degree of PI/ECO-similarity revealed high statistical heterogeneity and wide prediction intervals across PI/ECO-dissimilar BoE pairs. CONCLUSIONS On average, the pooled effect estimates between RCTs and cohort studies did not differ. Statistical heterogeneity and wide prediction intervals were mainly driven by PI/ECO-dissimilarities (i.e., clinical heterogeneity) and cohort studies. The potential influence of risk of bias and certainty of the evidence on differences of effect estimates between RCTs and cohort studies needs to be explored in upcoming meta-epidemiological studies.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Sara Balduzzi
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Maria Petropoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany.
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24
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Hatcher JB, de Castro-Abeger A, LaRue RW, Hingorani M, Mawn L, Donahue SP, Sternberg P, Shieh C. MRSA Decolonization and the Eye: A Potential New Tool for Ophthalmologists. Semin Ophthalmol 2022; 37:541-553. [DOI: 10.1080/08820538.2022.2039220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jeremy B Hatcher
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Alex de Castro-Abeger
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Richard W LaRue
- Department of Medicine, Division of Infectious Disease, Vanderbilt Medical Center, Nashville, TN, United States
| | - Melanie Hingorani
- Department of Paediatrics, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Louise Mawn
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sean P Donahue
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Paul Sternberg
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christine Shieh
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
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25
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Link T. Guidelines in Practice: Preoperative Patient Skin Antisepsis. AORN J 2022; 115:156-166. [PMID: 35084763 DOI: 10.1002/aorn.13605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 11/12/2022]
Abstract
Surgical site infections (SSIs) frequently involve resident bacteria (eg, Staphylococcus aureus) on the patient's skin. Strategies to help prevent SSIs include removing soil and transient microorganisms from the skin before surgery. Preoperative decolonization, preoperative bathing, and application of an effective skin antiseptic at the surgical site are components of a multimodal approach to reducing microorganisms to subpathogenic levels. As members of an interdisciplinary team, perioperative RNs are essential in the development and implementation of SSI prevention bundles to promote patient safety. This article discusses recommendations from the AORN "Guideline for preoperative patient skin antisepsis" for decolonization protocols, preoperative bathing, and selection of surgical site antiseptics. A scenario describes the process a facility team uses to determine components of an SSI prevention bundle after recognizing an increase in infections from multidrug-resistant organisms.
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26
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Bastos LR, Almeida MM, Marques EA, Leão RS. Colonização pré-operatória por Staphylococcus aureus e as bactérias não suscetíveis à cefalosporina, em pacientes com fratura proximal do fêmur. Rev Bras Ortop 2022; 57:726-733. [PMID: 36226207 PMCID: PMC9550373 DOI: 10.1055/s-0041-1735546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/07/2021] [Indexed: 11/30/2022] Open
Abstract
Objective
To estimate the frequency of
Staphylococcus aureus
and cephalosporin nonsusceptible bacteria colonization in patients with proximal femoral fracture during preoperative hospitalization.
Methods
Prevalence and incidence assessment in 63 hospitalized patients over 1 year. The median time of pretreatment hospitalization was 12 days. Samples were collected from the nostrils, groin skin and anal mucosa during the pretreatment hospitalization and were tested by the disc-diffusion technique.
Results
The hospital colonization incidence and the prevalence of positive results were 14.3 and 44.4% for
S. aureus
; 3.2 and 6.4% for meticillin-resistant
S. aureus
; 28.6 and 85.7% for meticillin-resistant coagulase-negative
Staphylococcus
; 28.6 and 61.9% for cefazolin nonsusceptible
Enterobacteriaceae
(KFNSE); and 20.6 and 28.6% for cefuroxime nonsusceptible
Enterobacteriaceae
(CXNSE). In addition, factors such as to the duration of the pretreatment hospitalization period, being non-walker before fracture, antimicrobial use, American Society of Anesthesiologists (ASA) 4 surgical risk, and previous hospitalization, were related to an increase in the incidence of hospital acquisition and prevalence of colonization by the evaluated strains. The prevalence of colonization by KFNSE was three times higher than by CXNSE on admission, and twice as high at the time of fracture treatment.
Conclusion
There was a high incidence of hospital colonization and prevalence of colonization by all strains studied, which may guide the indication of prophylactic measures for infection.
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Affiliation(s)
- Leonardo R. Bastos
- Seção de Ortopedia e Traumatologia, Hospital Geral de Fortaleza/Exército Brasileiro, Fortaleza, CE, Brasil
- Departamento de Microbiologia, Imunologia e Parasitologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, RJ, Brasil
| | - Mila M. Almeida
- Departamento de Microbiologia, Imunologia e Parasitologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, RJ, Brasil
| | - Elizabeth A. Marques
- Departamento de Microbiologia, Imunologia e Parasitologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, RJ, Brasil
| | - Robson Souza Leão
- Departamento de Microbiologia, Imunologia e Parasitologia, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, RJ, Brasil
- Laboratórios de Bacteriologia e Micobactérias, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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27
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Hockett Sherlock S, Goedken CC, Balkenende EC, Dukes KC, Perencevich EN, Reisinger HS, Forrest GN, Pfeiffer CD, West KA, Schweizer M. Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration. FRONTIERS IN HEALTH SERVICES 2022; 2:920830. [PMID: 36925849 PMCID: PMC10012655 DOI: 10.3389/frhs.2022.920830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022]
Abstract
As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion. Trial registration ClinicalTrials.gov, identifier: NCT02216227.
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Affiliation(s)
- Stacey Hockett Sherlock
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Cassie Cunningham Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States
| | - Erin C Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Heather Schacht Reisinger
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States.,Institute for Clinical and Translational Science, The University of Iowa, Iowa City, IA, United States
| | - Graeme N Forrest
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Christopher D Pfeiffer
- Department of Hospital and Specialty Medicine, VA Portland Health Care System, Portland, OR, United States.,Department of Medicine, Oregon Health & Sciences University, Portland, OR, United States
| | - Katelyn A West
- VA Portland Healthcare System, Portland, OR, United States
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
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Lee AS, Huttner BD, Catho G, Harbarth S. Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings. Infect Dis Clin North Am 2021; 35:931-952. [PMID: 34752226 DOI: 10.1016/j.idc.2021.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.
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Affiliation(s)
- Andie S Lee
- Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, University of Sydney, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
| | - Benedikt D Huttner
- Division of Infectious Diseases, University of Geneva Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Gaud Catho
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
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29
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Surgical site infection prevention through bundled interventions in hip replacement surgery: A systematic review. Int J Surg 2021; 95:106149. [PMID: 34687953 DOI: 10.1016/j.ijsu.2021.106149] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bundles have shown to improve patient outcomes in several settings. Surgical site infections (SSIs) following joint replacement surgery are associated with severe outcomes. We aimed to determine the effectiveness of non-pathogen specific bundled interventions in reducing SSIs after hip arthroplasty procedures. MATERIALS AND METHODS A systematic review and meta-analysis were conducted according to the PRISMA statement guidelines (PROSPERO registration number CRD42020203031). PubMed, Embase and Cochrane databases were searched for studies evaluating SSI prevention bundles in hip replacement surgery, excluding studies evaluating pathogen-specific bundles. Records were independently screened by two authors. The primary outcome was the SSI rate in intervention and control groups or before and after bundle implementation. Secondary outcomes of interest were bundle compliance and the number and type of bundle components. A meta-analysis was conducted using raw data, by calculating pooled relative risk (RR) SSI estimates to assess the impact of bundled interventions on SSI reduction. RESULTS Eleven studies were included in the qualitative review and four studies comprising over 20 000 patients were included in the quantitative synthesis. All included studies found bundles were associated with reduced SSI rates. The pooled RR estimated from the fixed-effects model was 0.76 (95% confidence interval 0.61-0.96, p 0.022) with 49.8% heterogeneity. CONCLUSIONS Results support the effectiveness of non-pathogen specific bundled interventions in preventing SSIs following hip arthroplasty. A "core" group of evidence-based elements for bundle development were identified.
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30
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Commentary: Mediastinitis postcoronary artery bypass grafting: From awfully simple to simply awful. J Thorac Cardiovasc Surg 2021; 162:1131-1132. [DOI: 10.1016/j.jtcvs.2020.03.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 11/23/2022]
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31
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Temkin E, Margalit I, Nutman A, Carmeli Y. Surgical antibiotic prophylaxis in patients colonized with multidrug-resistant Gram-negative bacteria: practical and conceptual aspects. J Antimicrob Chemother 2021; 76:i40-i46. [PMID: 33534884 DOI: 10.1093/jac/dkaa496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Antibiotic resistance threatens the effectiveness of surgical antibiotic prophylaxis (SAP) regimens aimed at preventing surgical site infection (SSI). With a focus on procedures in which Gram-negative bacteria (GNB) are the main pathogens causing SSI, this review summarizes the evidence and describes how SAP must evolve in response to carriage of MDR GNB among surgical patients. Randomized controlled trials of SAP for carriers of resistant GNB require prohibitively large sample sizes. No professional guidelines address the topic of adapting SAP for known carriers of resistant GNB. For patients whose carrier status is unknown, the effects of different SAP strategies have been studied for transrectal ultrasound-guided prostate biopsy and colorectal surgery. The four possible strategies for SAP in the era of antibiotic resistance are: no SAP; universal standard SAP; pre-surgical screening for carriage of antibiotic-resistant pathogens before surgery and targeted SAP (i.e. broad-spectrum antibiotics only for those who screen positive); and universal broad-spectrum SAP. The prevalence of carriage determines the efficiency of each strategy. Decolonization is a potential adjunct to SAP.
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Affiliation(s)
- Elizabeth Temkin
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel
| | - Ili Margalit
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Amir Nutman
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yehuda Carmeli
- National Institute for Infection Control and Antibiotic Resistance, Ministry of Health, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
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32
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Hashimoto A, Miyamoto H, Kii S, Kobatake T, Shobuike T, Noda I, Sonohata M, Mawatari M. Time-dependent efficacy of combination of silver-containing hydroxyapatite coating and vancomycin on methicillin-resistant Staphylococcus aureus biofilm formation in vitro. BMC Res Notes 2021; 14:81. [PMID: 33653399 PMCID: PMC7927400 DOI: 10.1186/s13104-021-05499-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/23/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We developed a silver-containing hydroxyapatite (Ag-HA) coating to prevent periprosthetic joint infection (PJI). Methicillin-resistant Staphylococcus aureus (MRSA) is the main PJI-causing bacteria. Previously, we had reported the combined effect of Ag-HA coating and vancomycin (VCM) on MRSA biofilm formation 24 h after MRSA inoculation. In this study, we investigated the time-dependent efficacy of Ag-HA coating and VCM on MRSA biofilm formation on Ti discs in vitro by three-dimensional confocal laser scanning microscopic analysis. RESULTS For the Ti VCM and HA VCM groups, the total biofilm volumes per area at 96 h after MRSA inoculation were significantly larger than those at 48 h after MRSA inoculation, respectively (p < 0.001). In contrast, for the Ag-HA VCM group, the total biofilm volume per area at 96 h was significantly smaller than that at 48 h (p < 0.0001). Moreover, 96 h after MRSA inoculation, the total biofilm volume per area of the Ag-HA VCM groups was significantly smaller than those of the Ti VCM and HA VCM groups (p < 0.0001). Thus, the combination of Ag-HA and VCM might be useful for the prevention of MRSA-associated PJI.
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Affiliation(s)
- Akira Hashimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan.
| | - Hiroshi Miyamoto
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Sakumo Kii
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Tomoki Kobatake
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Takeo Shobuike
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Iwao Noda
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan.,Research Section, Medical Division, KYOCERA Corporation, 800 Ichimiyake, Yasu City, Shiga, 530-2362, Japan
| | - Motoki Sonohata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Nabeshima 5-1-1, Saga, 849-8501, Japan
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Wang L, Ji Q, Hu X. Role of targeted and universal mupirocin-based decolonization for preventing surgical-site infections in patients undergoing cardiothoracic surgery: A systematic review and meta-analysis. Exp Ther Med 2021; 21:416. [PMID: 33747157 PMCID: PMC7967856 DOI: 10.3892/etm.2021.9860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 11/29/2022] Open
Abstract
The purpose of the present study was to provide a systematic literature review and pool evidence on the efficacy of mupirocin-based decolonization protocol in reducing surgical-site infections (SSIs) in patients undergoing cardiothoracic (CT) surgery based on their Staphylococcus (S.) aureus carrier state. The PubMed, Embase, Ovid, BioMed Central, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched for studies comparing mupirocin-based decolonization with controls for reducing SSIs in patients following CT surgery. Studies were grouped based on the targeted population of intervention, i.e. carriers or all patients. A total of 17 studies were included. Of these, 8 studies used targeted mupirocin-based decolonization, while universal decolonization was performed in 9 studies. The results were conflicting for studies performing targeted decolonization and it was not possible to perform a meta-analysis due to non-homogenous studies. Pooled analysis of 34,859 patients indicated that universal mupirocin-based decolonization significantly reduced the risk of all SSIs [risk ratio (RR): 0.54; 95% CI: 0.40,0.75; I2=73.35%]. The intervention significantly reduced the risk of superficial SSIs (RR: 0.37; 95% CI: 0.25,0.55; I2=0%) but not of deep SSIs (RR: 0.45; 95% CI: 0.19,1.09; I2=80.67%). The results indicated a significantly reduced risk of S. aureus SSIs (SA-SSIs) with mupirocin-based decolonization (RR: 0.44; 95% CI: 0.32,0.61; I2=0%) but not for methicillin-resistant S. aureus (MRSA-SSIs; RR: 0.25; 95% CI: 0.05,1.28; I2=79.07%). Evidence on the role of targeted mupirocin-based decolonization to reduce SSIs after CT surgery was non-coherent and inconclusive. Analysis of low-quality retrospective studies suggested that universal mupirocin-based decolonization may reduce all SSIs, superficial SSIs and SA-SSIs, but not deep SSIs or MRSA-SSIs in patients after CT surgery.
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Affiliation(s)
- Li Wang
- Departments of Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
| | - Qi Ji
- Departments of Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
| | - Xiaoyan Hu
- Departments of Tongguan Operating Room, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu 222002, P.R. China
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Ribau AI, Collins JE, Chen AF, Sousa RJ. Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty. J Arthroplasty 2021; 36:752-766.e6. [PMID: 32950342 DOI: 10.1016/j.arth.2020.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Staphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA. METHODS PubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies. RESULTS A total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous. CONCLUSION Preoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.
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Affiliation(s)
- Ana I Ribau
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - Jamie E Collins
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ricardo J Sousa
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal; Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar do Porto and Grupo TrofaSaude - Hospital em Alfena, Portugal
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San-Juan R, Gotor-Pérez CA, López-Medrano F, Fernández-Ruiz M, Lora D, Lizasoain M, Silva JT, Ruiz-Ruigómez M, Corbella L, Rodríguez-Goncer I, Viedma E, Orellana MA, Renes Carreño E, Pérez-Vela JL, Benito-Arnaiz V, López-Gude MJ, Cortina-Romero JM, Aguado JM. Eradication of Staphylococcus aureus post-sternotomy mediastinitis following the implementation of universal pre-operative nasal decontamination with mupirocin: an interrupted time-series analysis. Clin Infect Dis 2021; 73:1685-1692. [PMID: 33513221 DOI: 10.1093/cid/ciab073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although pre-surgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing post-surgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to the lack of robust supporting evidence. We aimed to evaluate the role of pre-operative NDM in the annual incidence of S. aureus PSM at our institution. METHODS An interrupted time-series analysis, with autoregressive error model, was applied to our single-center cohort by comparing pre-intervention (1990-2003) and post-intervention period (2005 to 2018). Logistic regression was performed to analyze risk factors for S. aureus PSM. FINDINGS 12,236 sternotomy procedures were analyzed (6,370 [52.1%] and 5,866 [47.9%] in the pre-intervention and post-intervention periods, respectively). The mean annual percentage adherence to NDM estimated over the post-interventional period was 90.2%. Only four out of 127 total cases of S. aureus PSM occurred during the 14-years post-intervention period (0.68/1,000 sternotomies vs. 19.31/1,000 in pre-interventional period [p<0.0001]). Interrupted time-series analysis demonstrated a statistically significant annual reduction of S. aureus PSM trend of -9.85 cases per 1,000 sternotomies (-13.17 to -6.5, P-value< 0·0001) in 2005, with a decreasing trend maintained over the following five years with an estimated relative reduction of 84.8% (95% CI: 89·25 to 74·09). Chronic obstructive pulmonary disease was the single independent risk factor for S. aureus PSM (odds ratio: 3.7; 95% CI: 1.72-7.93) and was equally distributed in patients undergoing sternotomy during pre or post-intervention periods. INTERPRETATION Our experience suggests that the implementation of pre-operative NDM reduces significantly the incidence of S. aureus PSM.
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Affiliation(s)
- Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Consuelo Alejandra Gotor-Pérez
- Department of Cardiac Surgery, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - David Lora
- Clinical Research Unit, Instituto de Investigación Hospital "12 de Octubre" (imas12), Facultad de Estudios Estadísticos, Universidad Complutense de Madrid, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Manuel Lizasoain
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - José Tiago Silva
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Esther Viedma
- Department of Microbiology, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - María Angeles Orellana
- Department of Microbiology, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Emilio Renes Carreño
- Cardiac Surgery Postoperative Unit, Intensive Care Department, Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - José Luis Pérez-Vela
- Cardiac Surgery Postoperative Unit, Intensive Care Department, Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - Victoria Benito-Arnaiz
- Department of Cardiac Surgery, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - María Jesús López-Gude
- Department of Cardiac Surgery, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - José María Cortina-Romero
- Department of Cardiac Surgery, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre," Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Complutense University, Madrid, Spain
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Lin L, Ke ZY, Wang Y, Chen XL, Zhong D, Cheng S. Efficacy of preoperative screening and decolonization for staphylococcus aureus in total joint arthroplasty: A meta-analysis. Asian J Surg 2021; 44:807-818. [PMID: 33468375 DOI: 10.1016/j.asjsur.2020.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/18/2020] [Accepted: 12/23/2020] [Indexed: 01/11/2023] Open
Abstract
The purpose of this study is to conduct a meta-analysis to evaluate the efficacy of screening and decolonization protocol for Staphylococcus aureus (SA) in total joint arthroplasty (TJA). We systematically searched the electronic databases of PubMed, Embase and Cochrane databases for relevant literatures from January 2000 to September 2020. The outcomes were colonization rate, total-surgical site infection (SSI) rate, SA-SSI rate and methicillin-resistant Staphylococcus aureus (MRSA)-SSI rate. All calculations and statistical tests were performed using Stata 14.0 software. A total of 12 studies were eligible in this study. Compared with control group, the screening and decolonization group had lower risks in total-SSI (risk ratio (RR) = 0.52; 95% confidence interval (CI): 0.40-0.67), SA-SSI (RR = 0.48; 95% CI: 0.32-0.72) and MRSA-SSI (RR = 0.45; 95% CI: 0.21-0.96). The nasal SA colonization was found to be associated with higher accidences of SSI involving total-SSI (RR = 1.49; 95% CI: 1.02-2.18), SA-SSI (RR = 2.51; 95% CI: 0.97-6.50) and MRSA-SSI (RR = 7.84; 95% CI: 1.67-36.79). The colonization rate of SA was significantly reduced after decolonization. No difference was observed between universal decolonization and screening-based decolonization. In conclusion, colonization of SA is associated with increased risk of SSI in TJA. Screening and decolonization protocol are proven to be effective to reduce colonization of SA and present protective effects against SSI in TJA. Moreover, universal decolonization protocol is non-inferior to screening-based decolonization.
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Affiliation(s)
- Lu Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen-Yong Ke
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Lin Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dian Zhong
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Implementation of a surgical site infection prevention bundle: Patient adherence and experience. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e63. [PMID: 36168498 PMCID: PMC9495544 DOI: 10.1017/ash.2021.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/14/2021] [Indexed: 12/02/2022]
Abstract
We evaluated barriers and facilitators to patient adherence with a bundled intervention including chlorhexidine gluconate (CHG) bathing and decolonizing Staphylococcus aureus nasal carriers in a real-world setting. Survey data identified 85.5% adherence with home use of CHG as directed and 52.9% adherence with home use of mupirocin as directed.
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Abstract
Staphylococcus aureus infections are associated with increased morbidity, mortality, hospital stay, and health care costs. S aureus colonization has been shown to increase risk for invasive and noninvasive infections. Decolonization of S aureus has been evaluated in multiple patient settings as a possible strategy to decrease the risk of S aureus transmission and infection. In this article, we review the recent literature on S aureus decolonization in surgical patients, patients with recurrent skin and soft tissue infections, critically ill patients, hospitalized non-critically ill patients, dialysis patients, and nursing home residents to inform clinical practice.
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Affiliation(s)
- Sima L Sharara
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Lisa L Maragakis
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Yuan X, Chen K, Zhao W, Hu S, Yu F, Diao X, Chen X, Hu S. Open-label, single-centre, cluster-randomised controlled trial to Evaluate the Potential Impact of Computerisedantimicrobial stewardship (EPIC) on the antimicrobial use after cardiovascular surgeries: EPIC trial study original protocol. BMJ Open 2020; 10:e039717. [PMID: 33243799 PMCID: PMC7692825 DOI: 10.1136/bmjopen-2020-039717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Inappropriate antimicrobial use increases the prevalence of antimicrobial-resistant bacteria. Surgeons are reluctant to implement recommendations of guidelines in clinical practice. Antimicrobial stewardship (AMS) is effective in antimicrobial management, but it remains labour intensive. The computerised decision support system (CDSS) has been identified as an effective way to enable key elements of AMS in clinical settings. However, insufficient evidence is available to evaluate the efficacy of computerised AMS in surgical settings. METHODS AND ANALYSIS The Evaluate of the Potential Impact of Computerised AMS trial is an open-label, single-centre, two-arm, cluster-randomised, controlled trial, which aims to determine whether a multicomponent CDSS intervention reduces overall antimicrobial use after cardiovascular surgeries compared with usual clinical care in a specialty hospital with a big volume of cardiovascular surgeries. Eighteen cardiovascular surgical teams will be randomised 1:1 to either the intervention or the control arm. The intervention will consist of (1) re-evaluation alerts and decision support for the duration of antimicrobial treatment decision, (2) re-evaluation alerts and decision support for the choice of antimicrobial, (3) quality control audit and feedback. The primary outcome will be the overall systemic antimicrobial use measured in days of therapy (DOT) per admission and DOT per 1000 patient-days over the whole intervention period (6 months). Secondary outcomes include a series of indices to evaluate antimicrobial use, microbial resistance, perioperative infection outcomes, patient safety, resource consumption, and user compliance and satisfaction. ETHICS AND DISSEMINATION The Ethics Committee in Fuwai Hospital approved this study (2020-1329). The results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04328090.
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Affiliation(s)
- Xin Yuan
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kai Chen
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuang Hu
- National Clinical Research Centre of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Yu
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Information Centre, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xingwei Chen
- Department of Pharmacy, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- State Key Laboratory of Cardiovascular Disease, National Centre for Cardiovascular Diseases, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Abstract
Surgical site infection (SSI) can be a significant complication of cardiac surgery, delaying recovery and acting as a barrier to enhanced recovery after cardiac surgery. Several risk factors predisposing patients to SSI including smoking, excessive alcohol intake, hyperglycemia, hypoalbuminemia, hypo- or hyperthermia, and Staphylococcus aureus colonization are discussed. Various measures can be taken to abolish these factors and minimize the risk of SSI. Glycemic control should be optimized preoperatively, and hyperglycemia should be avoided perioperatively with the use of intravenous insulin infusions. All patients should receive topical intranasal Staphylococcus aureus decolonization and intravenous cephalosporin if not penicillin allergic.
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Affiliation(s)
- Shruti Jayakumar
- Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, MemorialCare Long Beach Medical Center, 2801 Atlantic Avenue, Long Beach, CA 90806, USA
| | - Marjan Jahangiri
- Department of Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK.
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Sharma A, Fernandez PG, Rowlands JP, Koff MD, Loftus RW. Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:233-241. [PMID: 32837343 PMCID: PMC7366489 DOI: 10.1007/s40140-020-00403-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
PURPOSE OF REVIEW This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety. RECENT FINDINGS Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention. SUMMARY Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.
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Affiliation(s)
- Archit Sharma
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
| | - Patrick G. Fernandez
- Department of Anesthesia, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E. 16th Ave, Aurora, CO 80045 USA
| | - John P. Rowlands
- Delaware Orthopaedic Specialists, Pain Management, 3401 Brandywine Parkway, Wilmington, DE 19803 USA
| | - Matthew D. Koff
- Department of Anesthesia and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756 USA
| | - Randy W. Loftus
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
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Obremskey WT, Metsemakers WJ, Schlatterer DR, Tetsworth K, Egol K, Kates S, McNally M. Musculoskeletal Infection in Orthopaedic Trauma: Assessment of the 2018 International Consensus Meeting on Musculoskeletal Infection. J Bone Joint Surg Am 2020; 102:e44. [PMID: 32118653 DOI: 10.2106/jbjs.19.01070] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fracture-related infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.
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Affiliation(s)
- William T Obremskey
- Department of Orthopaedic Trauma, Vanderbilt Medical Center, Nashville, Tennessee
| | | | | | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Stephen Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Martin McNally
- Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
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Rosenthal MD, Brown CJ, Loftus TJ, Vanzant EL, Croft CA, Martindale RG. Nutritional Management and Strategies for the Enterocutaneous Fistula. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00255-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Ning J, Wang J, Zhang S, Sha X. Nasal colonization of Staphylococcus aureus and the risk of surgical site infection after spine surgery: a meta-analysis. Spine J 2020; 20:448-456. [PMID: 31669610 DOI: 10.1016/j.spinee.2019.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/18/2019] [Accepted: 10/18/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Nasal colonization of Staphylococcus aureus may increase the risk of surgical site infection (SSI) after spine surgeries, although the results of previous studies were inconsistent. PURPOSE To evaluate the influences of nasal colonization of S. aureus, methicillin-susceptible SA, and methicillin-resistant SA (MRSA) on the incidence of SSI after spine surgery. STUDY DESIGN/SETTING Systematic review and meta-analysis. PATIENT SAMPLE Seven studies including 10,650 patients who underwent nasal swab examination before spine surgeries were included, and 221 patients had nasal colonization of MRSA at baseline. OUTCOME MEASURES Association between baseline nasal colonization of S. aureus, MRSA, and SSI after spine surgery. METHODS Relevant follow-up studies were identified through systematic searches of the PubMed, Embase, and Cochrane Library databases. A random effects model was applied to pool the results. Subgroup analyses were performed according to whether MRSA decolonization was applied. RESULTS During follow-up, a total of 244 SSI events occurred, including 57 MRSA-SSI events. Pooled results showed that nasal S. aureus (risk ratio [RR]=0.75, p=.22) or methicillin-susceptible SA colonization (RR=0.60, p=.22) did not significantly affect the risk of overall SSI after surgeries. However, nasal MRSA colonization was associated with significantly increased risks of overall SSI and MRSA-SSI (RR=2.52 and 6.21, respectively, both p<.001). Interestingly, the associations between nasal MRSA colonization and increased risks of overall and MRSA-SSI remained significant in studies without MRSA decolonization, but became insignificant in studies with MRSA decolonization. CONCLUSIONS Nasal MRSA colonization may be associated with increased risks of overall SSI and MRSA-SSI after spine surgeries, and nasal MRSA decolonization may be associated with a reduction of SSI in these patients.
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Affiliation(s)
- Jintang Ning
- Department of Pharmacy, Dongying People's Hospital, No. 317 Nanyi Rd, Dongying 257091, China
| | - Jimei Wang
- Department of Pharmacy, Dongying People's Hospital, No. 317 Nanyi Rd, Dongying 257091, China.
| | - Songzhen Zhang
- Department of Pharmacy, Dongying People's Hospital, No. 317 Nanyi Rd, Dongying 257091, China
| | - Xiaojuan Sha
- Department of Public Health, Qingdao Sanatorium, Qingdao 266000, China
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Scrimshire AB, Booth A, Fairhurst C, Reed M, Tadd W, Laverty A, Corbacho B, Torgerson D, McDaid C. Scaling up Quality Improvement for Surgical Teams (QIST) - avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial. Trials 2020; 21:234. [PMID: 32111244 PMCID: PMC7048022 DOI: 10.1186/s13063-020-4152-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/06/2020] [Indexed: 11/21/2022] Open
Abstract
Background Measures shown to improve outcomes for patients often fail to be adopted into routine practice in the NHS. The Institute for Health Improvement Breakthrough Series Collaborative (BSC) model is designed to support implementation at scale. This trial aims to assess the effectiveness and cost-effectiveness of quality improvement collaboratives (QICs) based on the BSC method for introducing service improvements at scale in the NHS. Methods Forty Trusts will be randomised (1:1) to introduce one of two protocols already shown to improve outcomes in patients undergoing elective total hip and knee replacement surgery. The intervention is improvement collaboratives based on the BSC model, a learning system that brings together a large number of teams to seek improvement focussed on a proven intervention. Collaboratives aim to deliver at scale, maximise local engagement and leadership and are designed to build capacity, enable learning and prepare for sustainability. Collaboratives involve Learning Sessions, Action Periods, and a summative congress. Trusts will be supported to introduce either: decolonisation for Methicillin Sensitive Staphylococcus aureus (MSSA) to reduce post-operative infection (QIST: Infection), or an anaemia optimisation programme to reduce peri-operative blood transfusions (QIST: Anaemia). Trusts will continue with their usual practice for whichever protocol they are not introducing. Anonymised data related to both infection and anaemia outcomes for patients undergoing hip or knee arthroplasty at all sites will mean that the two groups act as controls for each other. The primary outcome for the QIST: Infection collaborative is deep MSSA surgical site infection within 90 days of surgery, and for the QIST: Anaemia collaborative is blood transfusion within 7 days of surgery. Patient-level secondary outcomes include length of hospital stay and readmission, which will also inform the economic costings. Qualitative interviews will evaluate the support provided to teams. Discussion The scale of this trial brings considerable challenges and potential barriers to delivery. Anticipated challenges relate to recruiting and sustaining up to 40 organisations, each with its own culture and context. This complex project with multiple stakeholders across a large geographical area will be managed by experienced senior-level project leaders with a proven track record in advanced project management. The team should ensure effective project governance and communications. Trial registration ISRCTN, ISRCTN11085475. Prospectively registered on 15 February 2018.
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Affiliation(s)
- Ashley B Scrimshire
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK. .,Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK.
| | - Alison Booth
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Caroline Fairhurst
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | | | - Annie Laverty
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - Belen Corbacho
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - David Torgerson
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Catriona McDaid
- Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
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Nurjadi D, Last K, Klein S, Boutin S, Schmack B, Mueller F, Heeg K, Ruhparwar A, Heininger A, Zanger P. Nasal colonization with Staphylococcus aureus is a risk factor for ventricular assist device infection in the first year after implantation: A prospective, single-centre, cohort study. J Infect 2020; 80:511-518. [PMID: 32112885 DOI: 10.1016/j.jinf.2020.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess, whether S. aureus nasal colonization is a risk factor for infections in patients with durable ventricular assist device (VAD). METHODS Prospective, single-centre, cohort study (i) ascertaining S. aureus nasal colonization status of patients admitted for VAD-implantation and detecting time to first episode of VAD-specific or -related infection according to International Society for Heart and Lung Transplantation criteria during follow-up and (ii) comparing whole genomes of S. aureus from baseline colonization and later infection. RESULTS Among 49 patients (17 colonized, 32 non-colonized), S. aureus VAD-infections occurred with long latency after implantation (inter quartile range 76-217 days), but occurred earlier (log-rank test P = 0.006) and were more common (9/17, 52.9% vs. 4/32, 12.5%, P = 0.005; incidence rates 2.81 vs. 0.61/1000 patient days; incidence rate ratio 4.65, 95% confidence interval 1.30-20.65, P = 0.009) among those nasally colonized with S. aureus before implantation. We found a similar but less pronounced effect of colonization status when analysing its effect on all types of VAD-infections (10/17, 58.8% vs. 7/32, 21.9%, P = 0.01). These findings remained robust when adjusting for potential confounders and restricting the analysis to 'proven infections'. 75% (6/8) of paired S. aureus samples from colonization and VAD-infection showed concordant whole genomes. CONCLUSIONS In patients with durable VAD, S. aureus nasal colonization is a source of endogenous infection, often occurring months after device-implantation and affecting mostly the driveline. Hygiene measures interrupting the endogenous route of transmission in VAD-patients colonized with S. aureus long-term may about half the burden of infections and require clinical scrutiny.
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Affiliation(s)
- Dennis Nurjadi
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Katharina Last
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Sabrina Klein
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Sébastien Boutin
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Florian Mueller
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Klaus Heeg
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Department of Cardiac Surgery, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Alexandra Heininger
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany; Unit of Hospital Hygiene, Mannheim University Hospital, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim
| | - Philipp Zanger
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany; Heidelberg Institute of Global Health, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany.
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Zhu X, Sun X, Zeng Y, Feng W, Li J, Zeng J, Zeng Y. Can nasal Staphylococcus aureus screening and decolonization prior to elective total joint arthroplasty reduce surgical site and prosthesis-related infections? A systematic review and meta-analysis. J Orthop Surg Res 2020; 15:60. [PMID: 32075670 PMCID: PMC7031963 DOI: 10.1186/s13018-020-01601-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Background Nasal Staphylococcus aureus (S. aureus) screening and decolonization has been widely used to reduce surgical site infections (SSIs) prior to total knee and hip arthroplasty (TKA and THA). However, it remains considerably controversial. The aim of this study was to ascertain whether this scheme could reduce SSIs and periprosthetic joint infections (PJIs) following elective primary total joint arthroplasty (TJA). Methods A systematic search was performed in MEDLINE, Embase, and the Cochrane Library until October, 2019. Outcomes of interest included SSI, PJI, superficial infection, and different bacterial species that caused infections. Data from eligible studies were then extracted and synthesized. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated. We also performed additional analyses to evaluate whether there were differences in postoperative SSIs caused by S. aureus or other bacteria. Results Nine studies were included in our meta-analysis. The pooled data elucidated that nasal S. aureus screening and decolonization dramatically mitigated the risk of SSI, PJI, and superficial infection compared to nondecolonization group. The analysis of bacterial species causing infection also showed that the S. aureus infections postoperative were significantly decreased in the decolonization group. However, there was no statistical difference in the SSI caused by other bacteria between the two groups. Conclusion S. aureus screening and decolonization prior to elective primary THA and TKA could significantly decrease the risk of SSI and PJI. However, more robust studies are needed to further evaluate the impact of S. aureus screening and decolonization on infection risk after TJA.
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Affiliation(s)
- Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Yichuan People's Hospital, Jiuchang Road 21#, District Yichuan, Luoyang, Henan, China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Yuqing Zeng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
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Bauer A, Grünewald M, Eberhardt H, Schulz R, Martus P, Brüggenjürgen B, Joos S, Sturm H. Ambulatory screening and decontamination to prevent Staphylococcus aureus complications in patients undergoing elective surgery (STAUfrei): study protocol for a controlled intervention study. BMC Infect Dis 2020; 20:95. [PMID: 32005137 PMCID: PMC6995168 DOI: 10.1186/s12879-020-4804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical site infections (SSI) are the most common health care associated infections in German acute hospitals and can result in prolonged hospital stays, increased use of antibiotics and utilisation of care. Staphylococcus aureus bacteria (methicillin-resistant S Aureus (MRSA) and methicillin-susceptible S Aureus (MSSA)) are amongst the most prominent causes of SSI. While up to 90% of documented S Aureus colonization is already detectable prior to hospital admission, the majority of hygiene measures in Germany is focused on the hospital setting. It is hypothesized that early detection and decontamination of S Aureus colonization in primary care can prevent health care associated infections and reduce the number of S Aureus isolates in the hospital setting. METHODS This study is a controlled interventional study (N = 13,260) with a pre-post comparison. The intersectoral intervention (over 2 years) will encompass the following elements: ambulatory detection and decontamination of MRSA and MSSA prior to elective surgery combined with a structured follow-up care. Patients from the control group will be screened in the hospital setting, in accordance with the standard operating procedure (SOP) in routine care. The primary endpoint is the reduction of MRSA and MSSA colonization upon hospital admission. Secondary endpoints are complication rate (SSI), length of stay, recolonization of patients (3 and 6 months after release), patient and provider satisfaction, patient compliance and cost development. DISCUSSION In case of positive results, the chance of a widespread uptake and implementation in routine care are considered high. The active involvement of primary care providers in the implementation of screening and decontamination as well as follow-up care is a unique feature of this study. The positive resonance of primary care providers during the recruitment phase highlights the relevance of the topic to the participating actors. These efforts are coupled with patient education and specifically trained medical staff, promising a sustained impact. The STAUfrei care pathway can homogenize current practices in routine care and provide a template for further intersectoral cooperation. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00016615. Registered on April 1st, 2019.
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Affiliation(s)
- Antonia Bauer
- Institute of General Practice and Interprofessional Care, Faculty of Medicine of the Eberhard Karls University Tübingen, University Hospital Tübingen, Osianderstraße 5, 72076, Tübingen, Germany.
| | | | | | | | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University Hospital Tübingen, Tübingen, Germany
| | | | - Stefanie Joos
- Institute of General Practice and Interprofessional Care, Faculty of Medicine of the Eberhard Karls University Tübingen, University Hospital Tübingen, Osianderstraße 5, 72076, Tübingen, Germany
| | - Heidrun Sturm
- Institute of General Practice and Interprofessional Care, Faculty of Medicine of the Eberhard Karls University Tübingen, University Hospital Tübingen, Osianderstraße 5, 72076, Tübingen, Germany
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Sakoulas G, Geriak M, Nizet V. Is a Reported Penicillin Allergy Sufficient Grounds to Forgo the Multidimensional Antimicrobial Benefits of β-Lactam Antibiotics? Clin Infect Dis 2020; 68:157-164. [PMID: 29986019 DOI: 10.1093/cid/ciy557] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/07/2018] [Indexed: 12/18/2022] Open
Abstract
The majority of patients with reported penicillin allergy are not allergic when tested or challenged. Penicillin allergy testing has been shown to significantly reduce annual healthcare expenditures. Data have emerged showing β-lactams have multidimensional antibacterial effects in vivo, far beyond what is appreciated in standard bacteriological susceptibility testing media. These include enhancing bacterial killing by the innate immune system. Supporting the clinical relevance of these secondary underappreciated effects are recent clinical and pharmacoeconomic analyses that show worse outcomes in patients with reported penicillin allergies who receive non-β-lactam antibiotics when compared to their non-penicillin-allergic counterparts. This is particularly relevant in the treatment of Staphylococcus aureus bacteremia. This article reviews the tremendous advantages offered by β-lactam therapy and makes a strong case that the debunking of false penicillin allergies through a detailed allergy history and penicillin allergy testing should be a vital component of antimicrobial stewardship practices.
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Affiliation(s)
- George Sakoulas
- Sharp Memorial Hospital, San Diego, La Jolla.,School of Medicine, University of California, San Diego, La Jolla
| | | | - Victor Nizet
- School of Medicine, University of California, San Diego, La Jolla.,Skaggs School of Pharmacy, University of California, San Diego, La Jolla
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Nikolaev NS, Lyubimova LV, Pchelova NN, Preobrazhenskaya EV, Alekseeva AV. Treatment of Periprosthetic Infection with Silver-Doped Implants Based on Two-Dimensionally Ordered Linear Chain Carbon. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2019. [DOI: 10.21823/2311-2905-2019-25-4-98-108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- N. S. Nikolaev
- Federal Center of Traumatology, Orthopedics and Endoprosthesis Replacement;
Ulyanov Chuvash State University
| | - L. V. Lyubimova
- Federal Center of Traumatology, Orthopedics and Endoprosthesis Replacement
| | - N. N. Pchelova
- Federal Center of Traumatology, Orthopedics and Endoprosthesis Replacement
| | | | - A. V. Alekseeva
- Federal Center of Traumatology, Orthopedics and Endoprosthesis Replacement
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