Review| Volume 94, ISSUE 3, P295-304, November 2016

Download started.


Staphylococcus aureus and surgical site infections: benefits of screening and decolonization before surgery


      Surgical site infections (SSIs) are among the most common healthcare-associated infections, and contribute significantly to patient morbidity and healthcare costs. Staphylococcus aureus is the most common microbial cause. The epidemiology of S. aureus is changing with the dissemination of newer clones and the emergence of mupirocin resistance. The prevention and control of SSIs is multi-modal, and this article reviews the evidence on the value of screening for nasal carriage of S. aureus and subsequent decolonization of positive patients pre-operatively. Pre-operative screening, using culture- or molecular-based methods, and subsequent decolonization of patients who are positive for meticillin-susceptible S. aureus and meticillin-resistant S. aureus (MRSA) reduces SSIs and hospital stay. This applies especially to major clean surgery, such as cardiothoracic and orthopaedic, involving the insertion of implanted devices. However, it requires a multi-disciplinary approach coupled with patient education. Universal decolonization pre-operatively without screening for S. aureus may compromise the capacity to monitor for the emergence of new clones of S. aureus, contribute to mupirocin resistance, and prevent the adjustment of surgical prophylaxis for MRSA (i.e. replacement of a beta-lactam agent with a glycopeptide or alternative).


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hospital Infection
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Klevens R.M.
        • Edwards J.R.
        • Richards Jr., C.L.
        • et al.
        Estimated health care-associated infections and death in US hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Allegranzi B.
        • Bagheri Nejad S.
        • Combescure C.
        • et al.
        Burden of endemic health-care-associated infection in developing countries: systemic review and meta-analysis.
        Lancet. 2011; 377: 228-241
        • European Centre for Disease Prevention and Control
        Annual epidemiological report on communicable disease in Europe 2008: report on the state of communicable disease in the EU and EEA/EFTA countries.
        ECDC, Solna2008 (Available at: [last accessed September 2015])
        • Jenks P.J.
        • Laurent M.
        • McQuarry S.
        • Watkins R.
        Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital.
        J Hosp Infect. 2014; 86: 24-33
        • Kim D.H.
        • Spencer M.
        • Davidson S.M.
        • et al.
        Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery.
        J Bone Joint Surg Am. 2010; 92: 1820-1826
        • Gaynes R.P.
        • Culver D.H.
        • Horan T.C.
        • Edwards J.R.
        • Richards C.
        • Tolson J.S.
        Surgical site infections (SSI) rates in the United States, 1992–1998: the National Nosocomial Infection Surveillance System basic SSI risk index.
        Clin Infect Dis. 2001; 33: S69-S77
        • Gastmeier P.
        • Geffers C.
        • Brandt C.
        • et al.
        Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections.
        J Hosp Infect. 2006; 64: 16-22
        • Dohmen P.M.
        Economic burden of surgical site infections in cardiac surgery.
        J Med Microb Diagn. 2013; 2: 3
        • Dohmen P.M.
        Antibiotic resistance in common pathogens reinforces the need to minimize surgical site infections.
        J Hosp Infect. 2008; 70: S15-S20
        • Healthcare Infection Control Practices Advisory Committee
        Draft guideline for the prevention of surgical site infection.
        Centers for Disease Prevention and Control, Atlanta, GA2014
        • Anderson D.J.
        • Kaye K.S.
        • Chen L.F.
        • et al.
        Clinical and financial outcomes due to methicillin-resistant Staphylococcus surgical site infection: a multi-center matched outcomes study.
        Plos One. 2009; 4: e8305
        • Perencevich E.N.
        • Sands K.E.
        • Cosgrove S.E.
        • Guadagnoli E.
        • Meara E.
        • Platt R.
        Health and economic impact of surgical site infections diagnosed after hospital discharge.
        Emerg Infect Dis. 2003; 9: 196-203
        • Schweizer M.
        • Perencevich E.
        • McDanel J.
        • et al.
        Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram-positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis.
        BMJ. 2013; 346: f2743
        • Calfee D.P.
        Considering universal mupirocin decolonization as an option for preventing surgical site infections.
        Clin Infect Dis. 2016; 62: 637-639
        • Lindsay J.A.
        • Holden T.G.
        Staphylococcus aureus: superbug, super genome?.
        Trends Microbiol. 2004; 8: 378-385
        • David M.Z.
        • Daum R.S.
        • Bayer A.S.
        • et al.
        Staphylococcus aureus bacteraemia at 5 US academic medical centres, 2008–2011: significant geographic variation in community-onset infections.
        Clin Infect Dis. 2014; 59: 798-807
        • Feil E.J.
        • Cooper J.E.
        • Grundnann H.
        • et al.
        How clonal is Staphylococcus aureus?.
        J Bacteriol. 2003; 185: 3307-3316
        • Campbell S.J.
        • Deshmukh H.S.
        • Nelson C.L.
        • et al.
        Genotypic characteristics of Staphylococcus aureus isolates from a multinational trial of complicated skin and skin structre infections.
        J Clin Microbiol. 2008; 46: 678-684
        • Grundmann H.
        • Aanensen D.M.
        • van den Wijngaard C.C.
        • Spratt B.G.
        • Harmsen D.
        • Friedrich A.W.
        Geographic distribution of Staphylococcus aureus causing invasive infections in Europe: a molecular-epidemiological analysis.
        PLos Med. 2010; 7: e1000215
        • European Centre for Disease Prevention and Control
        Annual epidemiological report 2014. Antimicrobial resistance and healthcare-associated infections.
        ECDC, Solna2015
        • Johnson N.B.
        • Hayes L.D.
        • Brown K.
        • Hoo E.C.
        • Ethier K.A.
        CDC national health report: leading causes of morbidity and mortality and associated behavioral risk and protective factors – United States, 2005–2013.
        MMWR Surveill Summ. 2014; 63: 3-27
        • Woodford N.
        • Livermore D.M.
        Infections caused by Gram-positive bacteria: a review of the global challenge.
        J Infect. 2009; 59: S4-S16
        • Schaumburg F.
        • Alabi A.S.
        • Peters G.
        • Becker K.
        New epidemiology of Staphylococcus aureus infection in Africa.
        Clin Microbiol Infect. 2014; 20: 589-596
        • Grundmann H.
        • Schouls L.M.
        • Aanensen D.M.
        • et al.
        The dynamic changes of dominant clones of Staphylococcus aureus causing bloodstream infections in the European region: results of a second structured survey.
        EuroSurveill. 2014; 19: pii:20987
        • Monecke S.
        • Coombs G.
        • Shore A.C.
        • et al.
        A field guide to pandemic, epidemic and sporadic clones of methicillin-resistant Staphylococcus aureus.
        PLoS One. 2011; 6: e17936
        • Jurke A.
        • Köck R.
        • Becker K.
        • et al.
        Molecular epidemiology of meticillin-resistant Staphylococcus aureus (MRSA): think regionally but use globally uniform typing languages.
        EuroSurveill. 2013; 18: pii:20617
        • Okon K.O.
        • Shittu A.O.
        • Kudi A.A.
        • Umar H.
        • Becker K.
        • Schaumburg F.
        Population dynamics of Staphylococcus aureus from Northeastern Nigeria in 2007 and 2012.
        Epidemiol Infect. 2014; 142: 1737-1740
        • Schaumburg F.
        • Köck R.
        • Mellmann A.
        • et al.
        Population dynamics among methicillin resistant Staphylococcus aureus in Germany during a 6-year period.
        J Clin Microbiol. 2012; 50: 3186-3192
        • Nimmo G.R.
        USA300 abroad: global spread of a virulent strain of community-associated methicillin-resistant Staphylococcus aureus.
        Clin Microbiol Infect. 2012; 18: 725-734
        • Tenover F.C.
        • Goering R.V.
        Methicillin-resistant Staphylococcus aureus strain USA300: origin and epidemiology.
        J Antimicrob Chemother. 2009; 64: 441-446
        • Köck R.
        • Schaumburg F.
        • Mellmann A.
        • et al.
        Livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) as causes of human infection and colonization in Germany.
        PLoS One. 2013; 8: e55040
        • van Cleef B.A.
        • Monnet D.L.
        • Voss A.
        • et al.
        Livestock-associated methicillin-resistant Staphylococcus aureus in humans, Europe.
        Emerg Infect Dis. 2011; 17: 502-505
        • Shore A.C.
        • Coleman D.C.
        Staphylococcal cassette chromosome mec: recent advances and new insights.
        IntJ Med Microbiol. 2013; 303: 350-359
        • Becker K.
        • Ballhausen B.
        • Köck R.
        • Kriegeskorte A.
        Methicillin resistance in Staphylococcus isolates: the ‘mec alphabet’ with specific consideration of mecC, a mec homolog associated with zoonotic S. aureus lineages.
        Int J Med Microbiol. 2014; 304: 794-804
        • Miller L.G.
        • Perdreau-Remington F.
        • Rieg G.
        • et al.
        Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles.
        N Engl J Med. 2005; 352: 1445-1453
        • Gillet Y.
        • Issartel B.
        • Vanhems P.
        • et al.
        Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients.
        Lancet. 2002; 359: 753-759
        • Dufour P.
        • Gillet Y.
        • Bes M.
        • et al.
        Community-acquired methicillin-resistant Staphylococcus aureus infections in France: emergence of a single clone that produces Panton-Valentine leukocidin.
        Clin Infect Dis. 2002; 35: 819-824
        • Köck R.
        • Harlizius J.
        • Bressan N.
        • et al.
        Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) among pigs on German farms and import of livestock-related MRSA into hospitals.
        Eur J Clin Microbiol Infect Dis. 2009; 28: 1375-1382
        • Köck R.
        • Siam K.
        • Al-Malat S.
        • et al.
        Characteristics of hospital patients colonized with livestock-associated meticillin-resistant Staphylococcus aureus (MRSA) CC398 versus other MRSA clones.
        J Hosp Infect. 2011; 79: 292-296
      1. Price LB, Stegger M, Hasman H, et al. Staphylococcus aureus CC398: host adaptation and emergence of methicillin resistance in livestock. MBio 2012;3:pii:e00305–e0011.

        • van Cleef B.A.
        • Verkade E.J.
        • Wulf M.W.
        • et al.
        Prevalence of livestock-associated MRSA in communities with high pig-densities in The Netherlands.
        PLoS One. 2010; 5: e9385
        • Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut
        Empfehlungen zur Prävention und Kontrolle von Methicillin-resistenten Staphylococcus aureus-Stämmen (MRSA) in medizinischen und pflegerischen Einrichtungen. Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut.
        Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz. 2014; 57: 696-732
        • Lekkerkerk W.S.
        • van Wamel W.J.
        • Snijders S.V.
        • et al.
        What is the origin of livestock-associated methicillin-resistant Staphylococcus aureus clonal complex 398 isolates from humans without livestock contact? An epidemiological and genetic analysis.
        J Clin Microbiol. 2015; 53: 1836-1841
        • García-Álvarez M.
        • Holden M.T.
        • Lindsay H.
        • et al.
        Meticillin-resistant Staphylococcus aureus with a novel mecA homologue in human and bovine populations in the UK and Denmark: a descriptive study.
        Lancet Infect Dis. 2011; 11: 595-603
        • Shore A.C.
        • Deasy E.C.
        • Slickers P.
        • et al.
        Detection of staphylococcal cassette chromosome mec type XI encoding highly divergent mecA, mecI, mecR1, blaZ and ccr genes in human clinical clonal complex 130 methicillin-resistant Staphylococcus aureus.
        Antimicrob Agents Chemother. 2011; 55: 3765-3773
        • Ballhausen B.
        • Kriegeskorte A.
        • Schleimer N.
        • Peters G.
        • Becker K.
        The mecA homolog mecC confers resistance against β-lactams in Staphylococcus aureus irrespective of the genetic strain background.
        Antimicrob Agents Chemother. 2014; 58: 3791-3798
        • Becker K.
        • Larsen A.R.
        • Skov R.L.
        • et al.
        Evaluation of a modular multiplex-PCR methicillin-resistant Staphylococcus aureus (MRSA) detection assay adapted for mecC detection.
        J Clin Microbiol. 2013; 51: 1917-1919
        • Paterson G.K.
        • Larsen A.R.
        • Robb A.
        • et al.
        The newly described mecA homologue, mecALGA251, is present in methicillin-resistant Staphylococcus aureus isolates from a diverse range of host species.
        J Antimicrob Chemother. 2012; 67: 2809-2813
        • Cuny C.
        • Layer F.
        • Strommenger B.
        • Witte W.
        Rare occurrence of methicillin-resistant Staphylococcus aureus CC130 with a novel mecA homologue in humans in Germany.
        PLoS One. 2011; 6: e24360
        • Kriegeskorte A.
        • Ballhausen B.
        • Idelevich E.A.
        • et al.
        Human MRSA isolates with novel genetic homolog, Germany.
        Emerg Infect Dis. 2012; 18: 1016-1018
        • Loncaric I.
        • Kübber-Heiss A.
        • Posautz A.
        • et al.
        Characterization of methicillin-resistant Staphylococcus spp. carrying the mecC gene, isolated from wildlife.
        J AntimicrobChemother. 2013; 68: 2222-2225
        • Walther B.
        • Wieler L.H.
        • Vincze S.
        • et al.
        MRSA variant in companion animals.
        Emerg Infect Dis. 2012; 18: 2017-2020
        • Kavi J.
        • Andrews J.M.
        • Wise R.
        Mupirocin-resistant Staphylococcus aureus.
        Lancet. 1987; 330: 1472
        • Udo E.E.
        • Jacob L.E.
        • Mathew B.
        Genetic analysis of methicillin-resistant Staphylococcus aureus expressing high- and low-level mupirocin resistance.
        J Med Microbiol. 2001; 50: 909-915
        • Singh A.
        • Karimpour-Fard A.
        • Gill R.T.
        Increased mutation frequency in redox-impaired Escherichia coli due to RelA- and RpoS-mediated repression of DNA repair.
        Appl Environ Microbiol. 2010; 76: 5463-5470
        • Patel J.B.
        • Gorwitz R.J.
        • Jernigan J.A.
        Mupirocin resistance.
        Clin Infect Dis. 2009; 49: 935-941
        • Morton T.M.
        • Johnston J.L.
        • Patterson J.
        • Archer G.L.
        Characterization of a conjugative staphylococcal mupirocin resistance plasmid.
        Antimicrob Agents Chemother. 1995; 39: 1272-1280
        • Pérez-Roth E.
        • López-Aguilar C.
        • Alcoba-Florez J.
        • Méndez-Álvarez S.
        High-level mupirocin resistance within methicillin-resistant Staphylococcus aureus pandemic lineages.
        Antimicrob Agents Chemother. 2006; 50: 3207-3211
        • Hurdle J.G.
        • O'Neill A.J.
        • Mody L.
        • Chopra I.
        • Bradley S.F.
        In vivo transfer of high-level mupirocin resistance from Staphylococcus epidermidis to methicillin-resistant Staphylococcus aureus associated with failure of mupirocin prophylaxis.
        J Antimicrob Chemother. 2005; 56: 1166-1168
        • Hetem D.J.
        • Bootsma M.C.
        • Bonten M.J.
        Prevention of surgical site infections: decontamination with mupirocin based on preoperative screening for Staphylococcus aureus carriers or universal decontamination?.
        Clin Infect Dis. 2016; 62: 631-636
        • Pérez-Roth E.
        • Kwong S.M.
        • Alcoba-Florez J.
        • Firth N.
        • Méndez-Álvarez S.
        Complete nucleotide sequence and comparative analysis of pPR9, a 41.7-kilobase conjugative staphylococcal multiresistance plasmid conferring high-level mupirocin resistance.
        Antimicrob Agents Chemother. 2010; 54: 2252-2257
        • Lee A.S.
        • Macedo-Vinas M.
        • Francois P.
        • et al.
        Trends in mupirocin resistance in meticillin-resistant Staphylococcus aureus and mupirocin consumption at a tertiary care hospital.
        J Hosp Infect. 2011; 77: 360-362
        • Bathoorn E.
        • Hetem D.J.
        • Alphenaar J.
        • Kusters J.G.
        • Bonten M.J.
        Emergence of high-level mupirocin resistance in coagulase-negative staphylococci associated with increased short-term mupirocin use.
        J Clin Microbiol. 2012; 50: 2947-2950
        • Desroches M.
        • Potier J.
        • Laurent F.
        • Bourrel A.S.
        • Doucet-Populaire F.
        • Decousser J.W.
        Prevalence of mupirocin resistance among invasive coagulase-negative staphylococci and methicillin-resistant Staphylococcus aureus (MRSA) in France: emergence of a mupirocin-resistant MRSA clone harbouring mupA.
        J Antimicrob Chemother. 2013; 68: 1714-1717
        • Horner C.
        • Parnell P.
        • Hall D.
        • Kearns A.
        • Heritage J.
        • Wilcox M.
        Meticillin-resistant Staphylococcus aureus in elderly residents of care homes: colonization rates and molecular epidemiology.
        J Hosp Infect. 2013; 83: 212-218
        • Petinaki E.
        • Spiliopoulou I.
        • Kontos F.
        • et al.
        Clonal dissemination of mupirocin-resistant staphylococci in Greek hospitals.
        J Antimicrob Chemother. 2004; 53: 105-108
        • Ahmed M.O.
        • Elramalli A.K.
        • Amri S.G.
        • Abuzweda A.R.
        • Abouzeed Y.M.
        Isolation and screening of methicillin-resistant Staphylococcus aureus from health care workers in Libyan hospitals.
        East Mediterr Health J. 2012; 18: 37-42
        • Poovelikunnel T.
        • Gethin G.
        • Humphreys H.
        Mupirocin resistance: clinical implications and potential alternatives for the eradication of MRSA.
        J Antimicrob Chemother. 2015; 70: 2681-2692
        • Idelevich E.A.
        • von Eiff C.
        • Friedrich A.W.
        • et al.
        In vitro activity against Staphylococcus aureus of a novel antimicrobial agent, PRF-119, a recombinant chimeric bacteriophage endolysin.
        Antimicrob Agents Chemother. 2011; 55: 4416-4419
        • von Eiff C.
        • Kokai-Kun J.F.
        • Becker K.
        • Peters G.
        In vitro activity of recombinant lysostaphin against Staphylococcus aureus isolates from anterior nares and blood.
        Antimicrob Agents Chemother. 2003; 47: 3613-3615
        • Steed L.L.
        • Costello J.
        • Lohia S.
        • Jones T.
        • Spannhake E.W.
        • Nguyen S.
        Reduction of nasal Staphylococcus aureus carraige in health care professionals by treatment with a nonantibiotic, alcohol-based nasal antispetic.
        Am J Infect Control. 2014; 42: 841-846
        • Liu Q.
        • Zhao H.
        • Han L.
        • Shu W.
        • Wu Q.
        • Ni Y.
        Frequency of biocide-resistant genes and susceptibility to chlorhexidine in high-level mupirocin-resistant, methicillin-resistant Staphylococcus aureus (MuH MRSA).
        Diagn Microbiol Infect Dis. 2015; 82: 278-283
        • Lepainteur M.
        • Royer G.
        • Bourrel A.S.
        • et al.
        Prevalence of resistance to antiseptics and mupirocin among invasive coagulase-negative staphylococci from very preterm neonates in NICU: the creeping threat?.
        J Hosp Infect. 2013; 83: 333-336
        • Ghasemzadeh-Moghaddam H.
        • van Belkum A.
        • Harmat R.A.
        • van Wamel W.
        • Neela V.
        Methicillin-susceptible and -resistant Staphylococcus aureus with high-level antiseptic and low-level mupirocin resistance in Malaysia.
        Microb Drug Resist. 2014; 20: 472-477
        • Trouillet-Assant S.
        • Flammier S.
        • Sapin A.
        • et al.
        Mupirocin resistance in isolates of Staphylococcus spp. from nasal swabs in a tertiary hospital in France.
        J Clin Microbiol. 2015; 53: 2713-2715
        • Kaur D.C.
        • Chate S.S.
        Study of antibiotic resistance pattern in methicillin-resistant Staphylococcus aureus with special reference to newer antibiotics.
        J Glob Infect Dis. 2015; 7: 78-84
        • Biedenbach D.J.
        • Bouchillon S.K.
        • Johnson S.A.
        • Hoban D.J.
        • Hackel M.
        Susceptibility of Staphylococcus aureus to topical agents in the United States: a sentinel study.
        Clin Ther. 2014; 36: 953-960
        • Barros E.M.
        • Ceotto H.
        • Bastos M.C.
        • dos Santos K.R.
        • Giambiagi-deMarval M.
        Staphylococcus haemolyticus as an important hospital pathogen and carrier of methicillin resistance genes.
        J Clin Microbiol. 2012; 50: 166-168
        • Liu Q.Z.
        • Wu Q.
        • Zhang Y.B.
        • et al.
        Prevalence of clinical meticillin-resistant Staphylococcus aureus (MRSA) with high-level mupirocin resistance in Shanghai and Wenzhou, China.
        Int J Antimicrob Agents. 2010; 35: 114-118
        • Kresken M.
        • Hafner D.
        • Schmitz F.J.
        • Wichelhaus T.A.
        Resistenzsituation bei klinisch wichtigen Infektionserregern gegenüber Antibiotika in Deutschland und im mitteleuropäischen Raum. Bericht über die Ergebnisse einer multizentrischen Studie der Arbeitsgemeinschaft Empfindlichkeitsprüfungen & Resistenz der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. aus dem Jahre 2007.
        Antiinfectives Intelligence, Rheinbach2009
        • O'Shea S.
        • Cotter L.
        • Creagh S.
        • Lydon S.
        • Lucey B.
        Mupirocin resistance among staphylococci: trends in the southern region of Ireland.
        J Antimicrob Chemother. 2009; 64: 649-650
        • Shittu A.O.
        • Lin J.
        Antimicrobial susceptibility patterns and characterization of clinical isolates of Staphylococcus aureus in KwaZulu-Natal province, South Africa.
        BMC Infect Dis. 2006; 6: 125
        • Köck R.
        • Becker K.
        • Cookson B.
        • et al.
        Systematic literature analysis and review of targeted preventive measures to limit healthcare-associated infections by methicillin-resistant Staphylococcus aureus.
        Eurosurveill. 2014; 19: 23-49
        • Van Rijen M.
        • Bonten M.
        • Wenzel R.
        • Kluytmans J.
        Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers.
        Cochrane Database Syst Rev. 2008; 4: CD006216
        • Lee A.S.
        • Cooper B.
        • Malhotra-Kumar S.
        • et al.
        Comparison of strategies to reduce methicillin-resistant Staphylococcus aureus rates in surgical patients: a controlled multicentre interventional trial.
        Br Med J. 2013; 3: 1-18
        • Schweizer M.L.
        • Chiang H.-Y.
        • Septimus E.
        • et al.
        Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip or knee surgery.
        JAMA. 2015; 313: 2162-2171
        • Schelenz S.
        • Tucker D.
        • Georgeu C.
        • et al.
        Significant reduction of endemic MRSA acquisition and infection in cardiothoracic patients by means of an enhanced targeted infection control programme.
        J Hosp Infect. 2005; 60: 104-110
        • Edmiston Jr., C.E.
        • Ledeboer N.A.
        • Buchan B.W.
        • Spencer M.
        • Seabrook G.R.
        • Leaper D.
        Is staphylococcal screening and suppression an effective interventional strategy for reduction of surgical site infection?.
        Surg Infect. 2016; 17: 1-9
        • Chen A.F.
        • Wessel C.B.
        • Rao N.
        Staphylococcus aureus screening and decolonisation in orthopaedic surgery and reduction of surgical site infections.
        Clin Orthop Relat Res. 2013; 471: 2383-2399
        • van Rijen M.M.
        • Bode L.G.
        • Baak D.A.
        • Kluytmans J.A.
        • Vos M.C.
        Reduced costs for Staphylococcus aureus carriers treated prophylactically with mupirocin and chlorhexidine in cardiothoracic and orthopaedic surgery.
        PloS One. 2012; 7: e43065
        • Harbarth S.
        • Fankhauser C.
        • Schrenzel J.
        • et al.
        Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients.
        JAMA. 2008; 299: 1149-1157
        • Bode L.G.
        • Kluytmans J.A.
        • Wertheim H.F.
        • et al.
        Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.
        N Engl J Med. 2010; 362: 9-17
        • Bode L.G.
        • Rijen M.M.
        • Wertheim H.F.
        • et al.
        Long-term mortality after rapid screening and decolonization of Staphylococcus aureus carriers: observational follow-up study of a randomised, placebo-controlled trial.
        Ann Surg. 2016; 263: 511-515
        • Spencer M.
        • Gulczynski D.
        Stop SSIs in their track.
        OR Nurse. 2010; 4: 38-42
        • Villamaria F.C.
        • Berlanga G.
        • Liao I.C.
        • et al.
        Comparison of environmental MRSA levels on high touch surfaces in contact isolation and noncontact isolation patient rooms.
        Infect Control Hosp Epidemiol. 2015; 36: 1472-1475
        • Hardy K.J.
        • Oppenheim B.A.
        • Gossain S.
        • Gao F.
        • Hawkey P.M.
        A study of the relationship between environmental contamination with methicillin-resistant Staphylococcus aureus and patients’ acquisition of MRSA.
        Infect Control Hosp Epidemiol. 2006; 27: 127-132
        • Courville X.F.
        • Tomek I.V.
        • Kirkland K.B.
        • Birhle
        • Kantor S.R.
        • Finlayson S.R.G.
        Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis.
        Infect Control Hosp Epidemiol. 2012; 33: 152-159
        • Wassenberg M.W.
        • de Wit G.A.
        • Bonten M.J.
        Cost-effectiveness of preoperative screening and eradication of Staphylococcus aureus carriage.
        PLoS Med. 2011; 6: e14815
        • Lee B.Y.
        • Wiringa A.E.
        • Bailey R.R.
        • et al.
        Screening cardiac surgery patients for MRSA: an economic computer model.
        Am J Manag Care. 2013; 16: e163-e173
        • Lee B.Y.
        • Tsui B.Y.
        • Bailey R.R.
        • et al.
        Should vascular surgery patients be screened pre-operatively for methicillin-resistant Staphylococcus aureus?.
        Infect Control Hosp Epidemiol. 2009; 30: 1158-1165
        • Clancy C.J.
        • Bartsch S.M.
        • Nguyegn M.H.
        • Stuckey D.R.
        • Shields R.K.
        • Lee B.Y.
        A computer simulation model of the cost-effectiveness of routine Staphylococcus aureus screening and decolonisation among lung and heart-lung transplant recipients.
        Eur J Clin Microbiol Infect Dis. 2014; 33: 1053-1061
        • Huang S.S.
        • Septimus E.
        • Kleinman K.
        • et al.
        Targeted versus decolonization to prevent ICU infection.
        N Engl J Med. 2013; 368: 2255-2265
        • Upton A.
        • Lang S.
        • Heffernan H.
        Mupirocin and Staphyloccoccus aureus: a recent paradigm of emerging antibiotic resistance.
        J Antimicrob Chemother. 2003; 51: 613-617
        • Harbarth S.
        • Dharan S.
        • Liassine N.
        • Herrault P.
        • Auckenthaler R.
        • Pittet D.
        Randomized, placebo-controlled, double-blind trial to evaluate the efficacy of mupirocin for eradicating carriage of methicillin-resistant Staphylococcus aureus.
        Antimicrob Agents Chemother. 1999; 43: 1412-1416
        • Robicsek A.
        • Beaumont J.L.
        • Thomson R.B.
        • Govindarajan G.
        • Peterson L.R.
        Topical therapy for methicillin-resistant Staphylococcus aureus colonisation: impact on infection risk.
        Infect Control Hosp Epidemiol. 2009; 30: 623-632
        • Vivoni A.M.
        • Santos K.R.
        • de-Oliveira M.P.
        • et al.
        Mupirocin for controlling methicilin-resistant Staphylococcus aureus: lessons from a decade of use at a university hospital.
        Infect Control Hosp Epidemiol. 2005; 26: 662-667
        • Deeny S.R.
        • Worby C.J.
        • Tosas-Auget O.
        • et al.
        Impact of mupirocin resistance on the transmission and control of healthcare-associated MRSA.
        J Antimicrob Chemother. 2015; 70: 3366-3378