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Thirteen-year experience with universal Staphylococcus aureus nasal decolonization prior to cardiac surgery: a quasi-experimental study

      Summary

      Introduction

      Sternal wound infection (SWI) after cardiac surgery is a severe complication. Among preventive measures, pre-operative decolonization of nasal carriage of Staphylococcus aureus has recently been shown to be beneficial. This quasi-experimental study assessed the effect of decolonization on the incidence of S. aureus-associated SWI based on 19 years of prospective surveillance.

      Methods

      Segmented negative binomial regression was used to analyse the change over time in the incidence of S. aureus mediastinitis requiring re-operation after cardiac surgery in a French university hospital between 1996 and 2014. Universal nasal decolonization with mupirocin was introduced in December 2001. The association between pre-operative nasal carriage and SWI due to S. aureus was analysed between 2006 and 2012.

      Results

      Among 17,261 patients who underwent a cardiac surgical procedure, 565 developed SWI (3.3%), which was caused by S. aureus in 181 cases (1%). The incidence of mediastinitis caused by S. aureus decreased significantly over the study period (1.43% in 1996–2001 vs 0.61% and 0.64% in 2002–2005 and 2006–2014, respectively; P<0.001). In segmented analysis, there was a significant break in 2002, corresponding to the introduction of decolonization. Despite this intervention, pre-operative nasal carriage remained a significant risk factor for S. aureus mediastinitis (adjusted odds ratio 2.2; 95% confidence interval 1.2–4.2), as were obesity, critical pre-operative status, coronary artery bypass grafting (CABG), and combined surgery with valve replacement and CABG.

      Conclusion

      Universal nasal decolonization before cardiac surgery was effective in decreasing the incidence of mediastinitis caused by S. aureus. Nasal carriage of S. aureus remained a risk factor for S. aureus-associated SWI.

      Keywords

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      References

        • Lepelletier D.
        • Perron S.
        • Bizouarn P.
        • Caillon J.
        • Drugeon H.
        • Michaud J.-L.
        • et al.
        Surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors.
        Infect Control Hosp Epidemiol Off J Soc Hosp Epidemiol Am. 2005; 26: 466-472
        • Finkelstein R.
        • Rabino G.
        • Mashiah T.
        • Bar-El Y.
        • Adler Z.
        • Kertzman V.
        • et al.
        Surgical site infection rates following cardiac surgery: the impact of a 6-year infection control program.
        Am J Infect Control. 2005; 33: 450-454
        • Fowler Jr., V.G.
        • O'Brien S.M.
        • Muhlbaier L.H.
        • Corey G.R.
        • Ferguson T.B.
        • Peterson E.D.
        Clinical predictors of major infections after cardiac surgery.
        Circulation. 2005; 112: I358-I365
        • Lemaignen A.
        • Birgand G.
        • Ghodhbane W.
        • Alkhoder S.
        • Lolom I.
        • Belorgey S.
        • et al.
        Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation.
        Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2015; 21 (674.e11–8)
        • Kubota H.
        • Miyata H.
        • Motomura N.
        • Ono M.
        • Takamoto S.
        • Harii K.
        • et al.
        Deep sternal wound infection after cardiac surgery.
        J Cardiothorac Surg. 2013; 8: 132
        • Charbonneau H.
        • Maillet J.M.
        • Faron M.
        • Mangin O.
        • Puymirat E.
        • Le Besnerais P.
        • et al.
        Mediastinitis due to Gram-negative bacteria is associated with increased mortality.
        Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2014; 20: O197-O202
        • Cossin S.
        • Malavaud S.
        • Jarno P.
        • Giard M.
        • L'Hériteau F.
        • Simon L.
        • et al.
        Surgical site infection after valvular or coronary artery bypass surgery: 2008–2011 French SSI national ISO-RAISIN surveillance.
        J Hosp Infect. 2015; 91: 225-230
        • Kirmani B.H.
        • Mazhar K.
        • Saleh H.Z.
        • Ward A.N.
        • Shaw M.
        • Fabri B.M.
        • et al.
        External validity of the Society of Thoracic Surgeons risk stratification tool for deep sternal wound infection after cardiac surgery in a UK population.
        Interact Cardiovasc Thorac Surg. 2013; 17: 479-484
        • Ridderstolpe L.
        • Gill H.
        • Granfeldt H.
        • Åhlfeldt H.
        • Rutberg H.
        Superficial and deep sternal wound complications: incidence, risk factors and mortality.
        Eur J Cardiothorac Surg. 2001; 20: 1168-1175
        • Lucet J.-C.
        • Parisian Mediastinitis Study Group
        Surgical site infection after cardiac surgery: a simplified surveillance method.
        Infect Control Hosp Epidemiol Off J Soc Hosp Epidemiol Am. 2006; 27: 1393-1396
        • Mekontso Dessap A.
        • Vivier E.
        • Girou E.
        • Brun-Buisson C.
        • Kirsch M.
        Effect of time to onset on clinical features and prognosis of post-sternotomy mediastinitis.
        Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2011; 17: 292-299
        • Morikane K.
        • Honda H.
        • Yamagishi T.
        • Suzuki S.
        Differences in risk factors associated with surgical site infections following two types of cardiac surgery in Japanese patients.
        J Hosp Infect. 2015; 90: 15-21
        • Allen K.B.
        • Fowler V.G.
        • Gammie J.S.
        • Hartzel J.S.
        • Onorato M.T.
        • DiNubile M.J.
        • et al.
        Staphylococcus aureus infections after elective cardiothoracic surgery: observations from an international randomized placebo-controlled trial of an investigational S aureus vaccine.
        Open Forum Infect Dis. 2014; 1: ofu071
        • van Rijen M.
        • Bonten M.
        • Wenzel R.
        • Kluytmans J.
        Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers.
        Cochrane Database Syst Rev. 2008; 4CD006216
        • Bode L.G.M.
        • Kluytmans J.A.J.W.
        • Wertheim H.F.L.
        • Bogaers D.
        • Vandenbroucke-Grauls C.M.J.E.
        • Roosendaal R.
        • et al.
        Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.
        N Engl J Med. 2010; 362: 9-17
        • Centers for Disease Control and Prevention/National Healthcare Safety Network
        CDC/NHSN surveillance definitions for specific types of infections.
        CDC, Atlanta, GA2014 (Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf [last accessed December 2016])
        • Birgand G.
        • Radu C.
        • Alkhoder S.
        • Al Attar N.
        • Raffoul R.
        • Dilly M.-P.
        • et al.
        Does a gentamicin-impregnated collagen sponge reduce sternal wound infections in high-risk cardiac surgery patients?.
        Interact Cardiovasc Thorac Surg. 2013; 16: 134-141
        • Parienti J.J.
        • Thibon P.
        • Heller R.
        • Le Roux Y.
        • von Theobald P.
        • Bensadoun H.
        • et al.
        Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study.
        JAMA. 2002; 288: 722-727
        • Wyllie D.H.
        • Walker A.S.
        • Miller R.
        • Moore C.
        • Williamson S.R.
        • Schlackow I.
        • et al.
        Decline of meticillin-resistant Staphylococcus aureus in Oxfordshire hospitals is strain-specific and preceded infection-control intensification.
        BMJ Open. 2011; 1e000160
        • Benneyan J.C.
        • Lloyd R.C.
        • Plsek P.E.
        Statistical process control as a tool for research and healthcare improvement.
        Qual Saf Health Care. 2003; 12: 458-464
        • Shardell M.
        • Harris A.D.
        • El-Kamary S.S.
        • Furuno J.P.
        • Miller R.R.
        • Perencevich E.N.
        Statistical analysis and application of quasi experiments to antimicrobial resistance intervention studies.
        Clin Infect Dis Off Publ Infect Dis Soc Am. 2007; 45: 901-907
        • Roques F.
        • Nashef S.A.
        • Michel P.
        • Gauducheau E.
        • de Vincentiis C.
        • Baudet E.
        • et al.
        Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients.
        Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 1999; 15 (discussion 822–3): 816-822
        • Ambler G.
        • Omar R.Z.
        • Royston P.
        A comparison of imputation techniques for handling missing predictor values in a risk model with a binary outcome.
        Stat Methods Med Res. 2007; 16: 277-298
        • R Core Team
        R: A language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna2014 (Available at: https://www.R-project.org/ [last accessed June 2014])
        • Perl T.M.
        • Cullen J.J.
        • Wenzel R.P.
        • Zimmerman M.B.
        • Pfaller M.A.
        • Sheppard D.
        • et al.
        Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections.
        N Engl J Med. 2002; 346: 1871-1877
        • Wassenberg M.W.M.
        • de Wit G.A.
        • Bonten M.J.M.
        Cost-effectiveness of preoperative screening and eradication of Staphylococcus aureus carriage.
        PloS One. 2011; 6e14815
        • Hong J.C.
        • Saraswat M.K.
        • Ellison T.A.
        • Magruder J.T.
        • Crawford T.
        • Gardner J.M.
        • et al.
        Staphylococcus aureus prevention strategies in cardiac surgery: a cost-effectiveness analysis.
        Ann Thorac Surg. 2018; 105: 47-53
        • World Health Organization
        Global guidelines for the prevention of surgical site infection.
        WHO, Geneva2017
        • Humphreys H.
        • Becker K.
        • Dohmen P.M.
        • Petrosillo N.
        • Spencer M.
        • van Rijen M.
        • et al.
        Staphylococcus aureus and surgical site infections: benefits of screening and decolonization before surgery.
        J Hosp Infect. 2016; 94: 295-304
        • Trouillet-Assant S.
        • Flammier S.
        • Sapin A.
        • Dupieux C.
        • Dumitrescu O.
        • Tristan 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
        • Hetem D.J.
        • Bootsma M.C.J.
        • Bonten M.J.M.
        Prevention of surgical site infections: decontamination with mupirocin based on preoperative screening for Staphylococcus aureus carriers or universal decontamination?.
        Clin Infect Dis Off Publ Infect Dis Soc Am. 2016; 62: 631-636
        • Septimus E.J.
        • Schweizer M.L.
        Decolonization in prevention of health care-associated infections.
        Clin Microbiol Rev. 2016; 29: 201-222
        • Ramos N.
        • Stachel A.
        • Phillips M.
        • Vigdorchik J.
        • Slover J.
        • Bosco J.A.
        Prior Staphylococcus aureus nasal colonization: a risk factor for surgical site infections following decolonization.
        J Am Acad Orthop Surg. 2016; 24: 880-885
        • Price J.R.
        • Cole K.
        • Bexley A.
        • Kostiou V.
        • Eyre D.W.
        • Golubchik T.
        • et al.
        Transmission of Staphylococcus aureus between health-care workers, the environment, and patients in an intensive care unit: a longitudinal cohort study based on whole-genome sequencing.
        Lancet Infect Dis. 2017; 17: 207-214
        • Jarlier V.
        • Trystram D.
        • Brun-Buisson C.
        • Fournier S.
        • Carbonne A.
        • Marty L.
        • et al.
        Curbing methicillin-resistant Staphylococcus aureus in 38 French hospitals through a 15-year institutional control program.
        Arch Intern Med. 2010; 170: 552-559