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SSI rate decreased with use of decontamination protocol
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Among patients undergoing elective orthopaedic surgery with hardware implantation, the rate of surgical site infection was decreased by more than 50% with the use of preoperative MRSA decontamination with chlorhexidine washcloths, an oral rinse and intranasal povidone-iodine, according to study results.
“This protocol is low-cost, short and easy to implement, and may be considered as an additional prevention strategy for surgical site infections, not only in our studied population, but in other populations as well,” study co-author Serge P. Bebko, MD, told Orthopaedics Today Europe.
Decontamination protocol
Bebko and colleagues analyzed the outcomes of 709 patients who underwent elective orthopaedic surgery between October 2012 and December 2013. Of these patients, 344 were included prior to the implementation of a decontamination protocol and 365 were included after implementation. Patients included in the decontamination protocol watched an educational video about MRSA decontamination and were given chlorhexidine washcloths, an oral rinse and a nasal povidone-iodine solution to be used the night before and the morning of scheduled surgery.
Results showed no significant differences between the study groups for age, BMI, gender or comorbidities between the groups. Bebko and his colleagues found all patients in the intervention group completed the MRSA decontamination protocol and experienced a significantly lower surgical site infection (SSI) rate vs. the control group.
“[The decontamination protocol] has considerable economic implications,” Bebko said. “According to our study, it would be necessary to treat 37 patients in order to prevent one SSI. The cost of the protocol per patient being approximately $35, it would take just about $1,300 to potentially prevent an infection that could cost $73,000.”
Significant independent risk factors associated with the development of SSI 30 days after surgery included chronic obstructive pulmonary disease, and a duration of surgery that was longer than 150 minutes. MRSA decontamination was an independent predictor of not developing a SSI, according to multivariate logistic regression.
“We found interesting the fact that none of the infections in the intervention group were caused by MRSA,” Bebko said.
Limitations
According to Bebko, since the study consisted of mostly male patients with multiple comorbidities, the results should be interpreted with caution when applied to other populations. There is also the chance of potential confounding as the population was not randomized.
“Although we found a significant difference of MRSA carrier status rates between control and intervention groups, MRSA carrier status was just collected after decontamination, not before, so we were unable to directly correlate the SSI rates with decontamination rates in our population,” Bebko said.
“SSIs lead to considerable morbidity and financial burden for both the patient and health care professional,” he added. “Decontamination protocols significantly contribute to the reduction of SSIs but are not sufficient. Additional preoperative, perioperative and postoperative strategies need to be implemented together to ultimately achieve a significant impact in the reduction of SSIs.” – by Casey Tingle
- Reference:
- Bebko SP, et al. JAMA Surg. 2015;doi:10.1001/jamasurg.2014.3480.
- For more information:
- Serge P. Bebko, MD, can be reached at Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030 USA; email: bebko@alumni.bcm.edu.
Disclosure: Bebko reports no relevant financial disclosures.
Perspective
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Carlo L. Romanò, MD
Reducing surgical site infections (SSIs) through MRSA intranasal decontamination is not a new idea. It dates back more than 15 years now. A recent systematic review failed to show a significant effect. Apart from the many study limitations, most of which were acknowledged by the authors, including the short follow-up of only 30 days and the lack of randomization, I think the concept of reducing SSIs through nasal decolonization has a weak theoretical basis, by itself. Why should, if possible at all, nasal decolonization of patients reduce SSIs? MRSA also colonizes other sites in patients and at hospitals, on clothes and skin of doctors is not immune to its presence. MRSA infections are just a fraction of all SSIs.
This study shows an overall reduction of SSIs. If MRSA decolonization is the reason for the difference between groups, we should see a reduction of only MRSA infections. Moreover, is an SSI due to MRSA so different than one due to methicillin-resistant Staphylococcus epidermis or to a gram-negative strain? Reducing SSIs with low-cost solutions can be attractive. However, the large-scale application of decolonization efforts, if effective, is by no means an easy task and it may become another ritual with no real benefit. Before we introduce this approach in our clinical practice, much more convincing evidence should be provided.
- Reference:
- Levy PY, et al. Orthop Traumatol Surg Res. 2013;doi:10.1016/j.otsr.2013.03.030.
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