Preventing Surgical Site Infections Through Preoperative MRSA Decolonization

In a previous post I touched on the infection risk associated with surgical procedures in hospitals, and the very real health threat posed by surgical site infections (SSI’s). I’d like to revisit SSI’s (and will likely do so again in the future), since they represent the largest subset of hospital-acquired infections and are particularly related to Staphylococcus aureus and MRSA.

Because of the variety of surgical procedures out there, SSI’s encompass a wide range of both costs and severities. S. aureus/MRSA, which causes far more SSI’s than any other type of bacteria, can add thousands of dollars to the cost of care for a single patient even when considering just minor surgeries.1 In complicated major surgeries that cost can stretch into the hundreds of thousands.2 These costs include everything from extended hospital stays to extra procedures, medicines, and diagnostic tests. Even apart from the human suffering caused by SSI’s, there is major economic incentive to keep rates as low as possible.

While it may take days or weeks for a surgical incision site to fully heal, it is generally accepted among infection control specialists that the high risk periods for contracting an SSI are during surgery and within 24 hours of completion of the procedure. These are the times when bacteria can enter the body through the incision site, contaminating the inside of the wound or even entering the bloodstream. Amazingly, by about 24 hours post-surgery the incision has actually sealed itself by epithelialization to the point where bacteria can no longer penetrate. Thus, when dealing with SSI’s doctors are facing an extremely high risk, yet very short and well-defined, period in which to implement preventive measures.

Everyone knows the care that is taken in hospital operating rooms to ensure that all surfaces, equipment, instruments, and clothing are sterilized to prevent the introduction of bacteria during surgery. Even the surgeons and nurses don’t enter the room until they’ve changed, scrubbed thoroughly, and covered their bodies with gowns and gloves. So in such a careful environment, where is all this SSI-causing bacteria coming from?  Increasing evidence is suggesting that the patients themselves are a major source of S. aureus/MRSA, and that so-called “self-infection” is a real issue when it comes to SSI’s.3, 4 It’s standard practice to disinfect the skin surface directly around the incision site before  cutting, but that isn’t always where the problem comes from. If you’ve read past posts you’ll remember that the nose and other skin surfaces can harbor high concentrations of pathogenic bacteria such as MRSA. In light of this, what is truly unbelievable is that it is not standard practice to make sure bacteria from these “self” sources is eliminated prior to surgery! Elimination of bacteria from the patient’s body before surgery, generally known medically as “decolonization therapy”, is not only not considered to be standard of care….its actually rare in North American hospitals.

Decolonization therapy is a concept that is quite controversial among medical professionals. On one hand, some assert that there’s not enough supporting evidence that decolonization has a measurable impact on SSI rate. On the other hand, there are the well-informed and up-to-date healthcare providers who have examined more recent published studies and seen the convincing results supporting decolonization. At a recent international infection control conference that I attended, one of the keynote speakers began his discussion of decolonization therapy by questioning the audience as to why we are still asking ourselves 1990’s questions (ie. does decolonization reduce infection rate) in 2010? Seems like a reasonable question, especially when the current literature taken together shows that identification and decolonization of S. aureus/MRSA carriers before surgery results in a 40-60% reduction in SSI rates. Furthermore, these types of results are now being reported consistently across surgical specialties as diverse as cardiac,5 orthopedic, 6, and gastroenterology.7

The good news is that more and more hospitals are moving out of the 1990’s and implementing various levels of presurgical decolonization therapy. It’s probably a reasonable question these days to ask your doctor or nurse before surgery about what measures they will take to ensure that your own potential sources of S. aureus and/or MRSA won’t contaminate your incision and lead to an SSI. The challenge going forward will hopefully be one of introducing better decolonization therapies to stay on the cutting edge of widespread infection prevention initiatives.

1 Broex et al. (2009) Journal of Hospital Infection 72:193-201

2 Noskin et al. (2005) Archives of Internal Medicine 165:1756-1761

3 Davis et al. (2004) Clinical Infectious Diseases 39:776-782

4 von Eiff et al. (2001) New England Journal of Medicine 344(1):11-16

5 Walsh et al. (2011) Archives of Internal Medicine 171(1):68-73

6 Lee et al. (2010) Infection Control and Hospital Epidemiology 31(11):1130-1138

7 Dupeyron et al. (2006) Journal of Hospital Infection 63:385-392

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5 Responses to “Preventing Surgical Site Infections Through Preoperative MRSA Decolonization”

  1. Tammy says:

    As the skin around any cut performed during surgery is prepared and made sterile with iodide or equivalent, skin bourne staph bacteria is going to be in limited supply. I’m not sure about the US but in the UK wounds aren’t disturbed in the first 24 hours unless needed. Staph aureus is a bacteria naturally occuring on the skin and in the respiratory areas (nose and throat) of most people.(commonly responsible for spots) Unfortunately in some cases this bacteria has become immune to antibacterials (all in strength up to methicillin hence the name Methicillin resistant staph aureus.) With correct hand washing and hygiene in hospitals most infections can be prevented. In the UK decolonisation is as simple as the person washing before surgery and each patient being swabbed for possible MRSA.

  2. Fabian says:

    Great article.

    If I was to undergo a surgery I am wondering what common practices I ought to do to reduce my risk of inheriting a SSI?

    What exactly is decolonization therapy? Does it go beyond blowing my nose? applying antibiotics topically to my nasal surfaces?

  3. Joan says:

    According to the CDC 25% to 30% of the population is colonized in the nose with staph bacteria. All patients and visitors coming into a hospital have the potential to be carriers. After surgery the immune system is weakened so the ability to aquire a staph greatly increases. Bacteria has been found in the nose of 25% to 30% of the people how did it get there? It must be in the air! Along with washing and sanitizing surfaces and patients it would seem logical to sanitize the air using photocatalytic oxidation as well. It has been shown to be more effective than the use of Ultraviolet light and filtration. Penn State College of Engineering has an article about it. Zandair understands it and uses it.

  4. ToryBurchx says:

    Thanks for your intriguing article. One other problem is that mesothelioma is generally the result of the inhalation of fibres from asbestos fiber, which is a cancer causing material. It’s commonly viewed among laborers in the building industry who’ve long exposure to asbestos. It is also caused by residing in asbestos insulated buildings for some time of time, Family genes plays a crucial role, and some people are more vulnerable towards the risk as compared to others.

    I should say also believe that mesothelioma is a rare form of cancer malignancy that is normally found in these previously familiar with asbestos. Cancerous cellular material form in the mesothelium, which is a safety lining that covers almost all of the body’s bodily organs. These cells commonly form while in the lining from the lungs, tummy, or the sac which actually encircles the heart. Thanks for expressing your ideas.

  5. Darin says:

    A recent article from Med Page was published concerning this very topic. It has been identified by the medical field as a very real problem, and steps are being taken to overcome it. Please discuss the potential of infection, the prevention, and testing you wish to have prior to surgery, and dont take “no” for an answer.

    That article can be found here:

    http://www.medpagetoday.com/surgery/otolaryngology/31276

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