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Preoperative Staphylococcus aureus Nasal Screening: Impact on Reducing Staphylococcus aureus Associated Surgical Sit

Preoperative Staphylococcus aureus Nasal Screening: Impact on Reducing Staphylococcus aureus Associated Surgical Site Infections . Mary Nicholson RN, BSN CIC The Christ Hospital Cincinnati, Ohio. TCH stats. 555 bed tertiary care hospital 25,840 admissions/year 44 ICU beds; ADC of 36

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Preoperative Staphylococcus aureus Nasal Screening: Impact on Reducing Staphylococcus aureus Associated Surgical Sit

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  1. Preoperative Staphylococcus aureus Nasal Screening: Impact on Reducing Staphylococcus aureus Associated Surgical Site Infections Mary Nicholson RN, BSN CIC The Christ Hospital Cincinnati, Ohio

  2. TCH stats 555 bed tertiary care hospital 25,840 admissions/year 44 ICU beds; ADC of 36 Services: Cardiac surgery (CVS), Orthopedic, Oncology, Neurosurgery, OB-Gyn, Renal Transplant, Medicine, and Pulmonary Internal Medicine Residency Program US News and World Report rankings (2008) Endocrinology (29) Heart & Heart Surgery (26), Neurology & Neurosurgery (34) Respiratory Disorders (38)

  3. Introduction • There are approximately 470,000 cardiovascular surgeries performed annually in the US. • The incidence of surgical site infections (SSI) is generally low at 1% to 8%, with an associated mortality rate of 14-47% • Complications and consequences associated with surgical site infections (SSI) are: • Increased morbidity and mortality • Prolonged hospitalizations • Increased health care costs – sometimes greater than 2.8 times the cost of an uncomplicated postoperative CVS patients • Jakob (2000) demonstrated the frequency of wound infections in CVS patients to be 1.9% to 15% with S aureus infections varying from 12% to 36.9% of the infections.

  4. Coronary Artery Bypass Surgery Bypass surgery consists of grafting veins or arteries from the aorta (a major artery that carries blood from the heart to the rest of the body) to the coronary artery, bypassing areas that are blocked.

  5. Sternal Wound Infections

  6. Sternal/Leg Wound Infections

  7. Medical Therapy: The use of a vacuum-assisted closure (VAC) device, allows for either sole therapy for sternal wound closure or adjunctive therapy in preparation for muscle flap closure. The principles of adequate wound debridement, treatment of infection, and closure of dead space still predominate as initial management decisions in treating sternal wounds. Radical Sternectomy With significant osteomyelitis of the sternum, fixing the sternum is impossible. The persistent infection results in a recurring sinus tracts and infectious drainage unless the infected bone and hardware are removed. Treatment of Sternal Wounds

  8. Rectus Abdominus Flap • Rectus abdominus muscle and 8th intercostal perforator for coverage of sternal defects

  9. Staphylococcus aureus • The most common pathogen causing SSI is Staphylococcus aureus (S. aureus). • S.aureus is endogenous to the human body with the primary site of colonization the anterior nares (Herwaldt 2003) • Weinstein (1959) noted there was a correlation between S.aureus and all types of SSI. • Kluytmans et al (1996) showed in a study that preoperative nasal carriage was the most important risk factor of surgical infections.

  10. Studies have determined ~ 25-30% of the population may be colonized at any given time with S.aureus • Carriers of S aureus are 2-9 times more likely as non- carriers to have SSI • Jakob also demonstrated 28.1% of his CVS patients showed nasal colonization of S aureus preoperatively with16% developing SSI, whereas the 71% patients with normal flora in their nares only 7.7% developed an SSI. • Ursy et al (2002) found in a CVS study over a 2 year period the SSI rate was 2.6% with S aureus accounting for 79.4% of that grouping

  11. Mupirocin Usage • Perl, et. al, (2002) conducted a randomized double blinded placebo controlled trial to determine whether intranasal mupirocin reduces the rate of S. aureus infections at surgical sites and prevents other nosocomial infections • 4030 patients were enrolled who underwent CVS, general surgery, neurosurgery, gynecologic procedures. • 891 patients who had S aureus in their anterior nares, 444 received mupirocin and 447 placebo • Among the patients with S aureus nasal carriage • 4.0% who received mupirocin had nosocomial S.aureus infections as compared with the 7.7% who received placebo Concluded mupirocin significantly reduced the rate of nosocomial infections due to S aureus, specifically among patients with nasal carriage of S aureus, the group expected to be at increased risk

  12. CVS TCH STATS • At this hospital S.aureus accounted for 80% of the SSI in CVS population • During the preceding 16 month period (Jan 02 –April 03) the overall CVS SSI rate was 1.89% (18 infs/per 954 procedures performed) • MRSA non-surgical isolates occurred in ~ 11 patients each year • Study reviews found using prophylactic mupirocin ointment applied to the nares decreased the incidence of S. aureus associated nosocomial infections • 2002 Quality control hospital statistics found the average cost to treat a deep sternal infection was $ 42,700.00

  13. Study Purpose • The objective of this study was to show that, with performing prescreening nasal cultures and with both pre- and postoperative treatment with mupirocin, there would be a significant decreases in SSI in CVS patients.

  14. Cost Impact • The cost impact of starting the project was estimated to be ~ $45,000 for approximately 900 patients • $12 for the S aureus screening nasal culture • ~ $38 for a 1 week supply of mupirocin • Based upon the 2002 costs of a deep sternal infection, if one infection was prevented it would pay for the cost of the project.

  15. Culture Protocol • All patient’s nares were cultured preoperatively using the Oxoid PenicillinBinding Protein Latex agglutination test before the patient skin was prepped in the operating room. • This screening test selects for S.aureus and reports both methicillin sensitive and resistant strains • After the nasal culture was obtained, each patient received an intranasal mupirocin application to each nares • The mupirocin application was continued every 12 hours until the culture results were available. • If the culture returned positive for S. aureus, mupirocin was continued for a total of 14 doses • If the culture returned negative, mupirocin was stopped

  16. CVS Procedures April 2003 - September 2004 1077 patients were studied

  17. Nasal screening results April 2003 – September 2004 Approximately, 22% of the patients were identified as nasal carriers

  18. Infections: Pre and Post Mupirocin

  19. SSI Results • 33% reduction in overall infections • 75% decrease in S. aureus associated infections (p < 0.006) • 90% decrease in deep sternal S.aureus infections ( p<0.0087) • Elimination of MRSA non-surgical isolates in this population and no incidences of MRSA pneumonia, UTIs or bacteremias

  20. Cost Impact of Deep SSI Pre vs. Post Mupirocin Post mupirocin costs include the $42k start up costs

  21. Total Joint Surgery Patients

  22. Total Joint Prosthesis

  23. Complications • Second to loosening of the prosthesis, infection is the most common complication of orthopedic implant procedures • Gram positive organisms such as S aureus and Coagulase negative staphylococcus are the predominant organisms in prosthetic joint infections and have occurred at a rate of 0.6 – 2.0% per 100 procedures

  24. Infection Pathways • Introduction of microorganisms during the operative procedure, contiguous spread of post-op wound infection or colonization by hematogenous seeding • The freshly implanted biomaterial is highly susceptible to infection – colonization by even small numbers of bacteria can lead to joint sepsis • During the early post-op period, when superficial infections can develop, the fascial layers have not healed and the deep periprosthetic tissue is not protected by usual physical barriers • Any factor that delays wound healing increases the risk such as: ischemic necrosis, hematoma, wound sepsis or suture abscesses

  25. Treatment Options • Joint irrigation with antibiotics • Antibiotic therapy without removal of prosthesis • 2 stage implant exchange • Prosthesis removal (infected bone, soft tissue and joint linings- called a synovectomy) • Followed by irrigation and implantation of an antibiotic implanted spacer • Treated with 6-8 week course of antibiotics • Once infection is cleared, joint is re-implanted • Arthrodesis- the surgical immobilization of a joint until the bone has healed

  26. Antibiotic Impregnated Joint

  27. TCH Ortho Stats • At TCH over 500 total joint surgeries are performed each year • The associated SSI rate had averaged 0.86% per 100 procedures over the previous 2 year period. S. aureus had accounted for 50% of the SSIs • SSI rate 2002 = 1.2% • SSI rate 2003 = 0.6%

  28. Hospital Stats In 2004, there was an increase in total joint SSIs with an associated rate of 1.49% (8/453). Upon further investigation • 5/8 of the SSI were caused by S.aureus (with 3/5 isolates were MRSA) • The patients and OR team underwent nasal cultures to rule out S. aureus nasal colonization • 4 patients and 1 OR team member was identified as S. aureus nasal carriers

  29. All S. aureus isolates were sent to the Ohio Department of Health for DNA pulse field gel electrophoresis typing (PFGE). • This included 5 patients and 1 OR team member’s nasal isolate • Six (6) different strains of S. aureus were identified • None of the strains were linked epidemiologically • One patient’s daughter was also hospitalized with MRSA sepsis and both patient and daughter shared the same strain of MRSA

  30. Protocol • Beginning in December 2004, all total joint patients when reporting for Pre Admission Testing (PAT) • Nasal cultures were obtained to rule out S. aureus • Cultures are sent to LabOne of Ohio using the Oxoid penicillin binding protein Latex agglutination test • Culture results would generally be available within 48 hours and before patient was admitted to hospital for surgery • In those cases where cultures had not been collected PTA, SDS are to send a nasal screening culture and begin intranasal mupirocin before surgery

  31. Treatment of Carriers • S.aureus sensitive carriers • To receive intranasal mupirocin BID for 7 days • IV cephazolin or clindamycin is to be administered as the pre-operative surgical antimicrobial • Mupirocin is to be continued during hospitalization if not completed pre-operatively • Follow-up culture to be obtained in surgeon’s office

  32. Treatment of Carriers • Methicillin resistant carriers • Toreceive intranasal mupirocin BID for 7 days • IV vancomycin is administered as the pre-operative surgical antimicrobial • Patients are instructed to shower with CHG soap • Patients are placed into Contact isolation upon admission to the hospital and continued until culture negative • Mupirocin is continued during hospitalization if not completed pre-operatively • Follow-up culture is obtained in surgeon office

  33. Total Joint ProceduresDec 04 - Dec 2005 Figure 1

  34. Nasal Culture Results (Dec 04 – Dec 05) 27% of patients were identified as S aureus carriers at the time of PAT

  35. Findings 27.3% (119/435) of total joint procedure patients were identified as S aureus nasal carriers at the time of pre-admission testing. 16.8% (20/119) of S aureus nasal isolates were MRSA strains. Zero (0) deep infections occurred during the post mupirocin treatment study period. There was one superficial SSI. There were no deep infections associated with S. aureus. The SSI rate post mupirocin, was 0.19% (1 infection / 534 procedures). There was an 82% reduction in overall SSIs in historical group (16/1467) to the treated group (p < 0.03).

  36. Infections Pre-mupirocin and Post-mupirocin

  37. Pre-op nasal screening results

  38. CVS screening results thru June 08

  39. Total Joint screening results

  40. Orthopedic spinal procedures

  41. Pre-op nasal screening impact on SSI

  42. Application of project and future directions • Pre-operative nasal screening may be applied to other services if S. aureus is a frequent source of SSIs • To be successful, efforts should be coordinated with surgeon offices, microbiology labs and hospitals • Obtaining a culture pre-operatively, eliminates the need to prophylactically treat all patients with a 7 day course of mupirocin; and should reduce the risks of drug resistance • Targeting vancomycin usage for MRSA carriers should minimize the risks of drug resistance

  43. MRSA stats at TCH

  44. MRSA surveillance at TCH Patients identified with MRSA – are placed in Contact isolation and records are “flagged”; so that when readmitted - placed in isolation until cultures return negative

  45. Recommendation from ICC • Continue pre-operative nasal screening for SAS/MRSA colonization • Expand the pre-op screening to include patients with other implantable devices (e.g. vascular grafts, ICD, etc). • Support the initiation of a surveillance study in MICU to determine baseline prevalence rate of MRSA nasal carriage (medical residents) • Continue to place all MRSA patients in Contact isolation until follow-up cultures return negative • Do not recommend MRSA hospital wide surveillance at this time.

  46. Awards and Publication 2004 Sodexho Health Care Services : Honorable Mention: Spirit of Excellence Award for Quality Nicholson, MR and Huesman LA. Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients. Am J Infect Control 2006; 34(1):44-48. Midwest Nursing Research Society Annual Meeting, Milwaukee April 2006 Poster presentation: Limiting the Usage of Intranasal Mupirocin Does Impact the Rate of Staphylococcus aureus Deep Sternal Wound Infections APIC Blue Ribbon Abstract Award 2006 – Tampa, June 2006: Poster Presentation: Pre-operative Staphylococcus aureus Nasal Screening does Reduce Total Joint Surgical Site Infections American College of of Orthopedic Surgeons – Poster presentation- February 2007: Screening for S. aureus does Reduce Total joint SSI. Anthem’s Hospital Quality Meritorious Award March 2007 Poster and Oral presentationsat National Orthopedic Nursing Association May 2007 and 2008.

  47. Our CVS Team

  48. Our Ortho Team

  49. Questions?? Thank you!

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