discussion paper - health quality & safety commission aureus preoperative screening nasal...

Discussion paper

Anti-staphylococcal bundle to

reduce surgical site infections in

orthopaedic and cardiac surgery

November 2016

Anti-staphylococcal bundle to reduce SSIs in orthopaedic and cardiac surgery – Discussion paper page 2

Contents

1. Purpose ......................................................................................................................... 3

2. Background .................................................................................................................... 4

3. Meta-analysis findings.................................................................................................... 6

4. Proposed bundle ............................................................................................................ 7

5. Benefits and risks ........................................................................................................... 8

6. Your feedback requested ............................................................................................... 9

Appendix 1: Orthopaedic SSIs caused by staphylococci: March 2013 to March 2016 ......... 10

Appendix 2: Overview of meta-analysis of S. aureus SSI prevention in orthopaedic and

cardiac surgery ................................................................................................................... 11

Appendix 3: Summary of bundle components from the papers in meta-analysis ................. 19

Appendix 4: SSI bundle costing .......................................................................................... 21

Appendix 5: Back of envelope cost–benefit analysis of an anti-staph bundle in New

Zealand ............................................................................................................................... 23

Appendix 6: Issues relating to screening for S. aureus carriage .......................................... 25

Appendix 7: Susceptibility of staphylococci in New Zealand ................................................ 26


1. Purpose

The Health Quality & Safety Commission (the Commission) is considering a bundle of anti-

staphylococcal interventions to reduce orthopaedic and cardiac surgical site infections (SSIs)

caused by staphylococci. The purpose of this paper is to seek the sector’s views on a

proposed bundle.

The potential components of an anti-staphylococcal bundle include:

Staphylococcus aureus preoperative screening

nasal decolonisation

skin decolonisation.

The Commission recently contracted the Royal Australasian College of Surgeons to conduct a systematic review and meta-analysis on all literature related to skin and intranasal decolonisation protocols specific to reducing the risk of staphylococcal SSIs in cardiac and orthopaedic surgical procedures. The review suggests there would be a patient benefit by introducing a standardised set of interventions to reduce the risk of staphylococcal SSIs in elective cardiac and orthopaedic procedures. Anti-staphylococcal bundles for elective surgical patients have been implemented internationally over the past two decades; however, preoperative screening methods and decolonisation agents vary greatly. Recent feedback from district health boards (DHBs) reveals that the current approaches to reducing the risk of staphylococcal SSIs range from no protocol to both preoperative screening and decolonisation protocols in cardiac and orthopaedic surgery. We seek your feedback regarding six issues (please refer to page 9 of this document). The information in this paper is provided to inform your considerations of the following six issues: 1. Potential benefit of introducing an anti-staphylococcal bundle in New Zealand

2. Universal decolonisation vs. preoperative screening

3. Povidone-iodine as first-choice nasal agent

4. Nasal treatment administered twice the day before and once the morning of surgery

5. Skin application administered twice the day before and once the morning of surgery

6. Both skin and nasal components should be part of the bundle.


2. Background

SSIs are associated with prolonged hospital stay and increased re-hospitalisation and mortality rates, as well as additional healthcare costs.1 In order to reduce the risk of SSIs, a number of interventions are used, and there is a drive for these to become applied in a consistent manner. Standard practice in hip, knee and cardiac surgery includes antibiotic prophylaxis with ≥ 2 g dose of cefazolin as the first-choice antibiotic (≥ 1.5 g of cefuroxime is an acceptable alternative) with vancomycin or clindamycin reserved for patients with β-lactam allergy. It is also recommended vancomycin should be added to cefazolin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The most commonly isolated pathogen in SSIs is Staphylococcus aureus.2,3 Staphylococcal infections cause the largest proportion of SSIs in New Zealand and globally. S. aureus accounts for about 30% of orthopaedic and cardiac SSIs identified in DHB patients. The current overall burden of staphylococcal SSI, due to pure growth cultures of staphylococci, is referenced in Appendix 1. Most patients who develop an S. aureus SSI are carriers of the strain causing the infection.4 In SSI cases, S. aureus isolates have been reported to match those from the patient’s nares approximately 85% of the time.5 S. aureus carriage is a well-established significant risk factor for prosthetic joint surgery as SSI rates are up to nine times greater among S. aureus carriers compared to non-carriers undergoing surgery.6 S. aureus lives on the human skin as a commensal. In developed countries, approximately 30% of the general adult population are colonised.7 Most colonised individuals who develop a staphylococcal infection at the site of a total joint arthroplasty have molecularly identical S. aureus isolates in their nares and wounds. The anterior nares is the most frequent carriage site for S. aureus.8 Other body sites that harbour this organism include the skin, perineum, pharynx, axillae, and gastrointestinal tract. For patients undergoing elective surgery, particularly procedures where implants are anticipated, preoperative screening for S. aureus and mupirocin for those identified as carriers is found to be a cost-effective means

1 Bratzler DW, Houck PM. 2005. Antimicrobial prophylaxis for surgery: An advisory statement from the

National Surgical Infection Prevention Project. American Journal of Surgery 189(4): 395–404. 2 Saadatian-Elahi M, Teyssou R, Vanhems P. 2008. Staphylococcus aureus, the major pathogen in

orthopaedic and cardiac surgical site infections: A literature review. International Journal of Surgery 6: 238–45. 3 Cantlon CA, Stemper ME, Schwan WR, et al. 2006. Significant pathogens isolation from surgical site

infections at a community hospital in the Midwest. American Journal of Infection Control 34(8): 526–9. 4 Kluytmans J, van Belkum A, Vergrugh H. 1997. Nasal carriage of Staphylococcus aureus:

epidemiology, underlying mechanisms, and associated risks. Clinical Microbiology Reviews 10: 505–20. 5 Perl TM, Cullen JJ, Wenzel RP, et al. 2002. Intranasal mupirocin to prevent postoperative

Staphylococcus aureus infections. New England Journal of Medicine 345: 1871–7. 6 Kalmeijer MD, van Nieuwland-Bollen D, Bogaers-Hofman D, et al. 2000. Nasal carriage of

Staphylococcus aureus is a major risk factor of surgical site infections in orthopedic surgery. Infection Control and Hospital Epidemiology 21(5): 319–23. 7 Coates T, Bax R, Coates A. 2009. Nasal decolonization of Staphylococcus aureus with mupirocin:

strengths, weaknesses, and future prospects. Journal of Antimicrobial Chemotherapy 64: 9–15. 8 Wertheim HFL, Melles DC, Vos MC, et al. 2005. The role of nasal carriage in Staphylococcus

aureus infections. The Lancet Infectious Disease 5: 751–62.


to reduce SSIs.9,10 However, the most commonly used agent for nasal decolonisation, mupirocin, comes with potential risk of resistance if widely employed. Protocols for the screening and/or decolonisation of S. aureus prior to implant surgery have become widely adopted internationally. Decolonisation is a strategy to reduce the patient’s microbial load of S. aureus just before their surgical procedure so their risk of infection is decreased. A recent study identified that screened and subsequently treated patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened and treated.11

An ‘anti-staphylococcal bundle’ consists of pre-theatre prophylactic nasal and/or skin decolonisation, in addition to standard care. Decolonisation often involves topical applications of ointment such as mupirocin or povidone-iodine with or without chlorhexidine body washes or wipes before admission to theatre.

9 Abad CL, Pulia MS, Safdar Nl. 2013. Does the nose know? An update on MRSA decolonization

strategies. Current Infectious Disease Reports 15(6):455–64. 10

Chen AF, Wessel CB, Rao N. 2013. Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections. Clinical Orthopaedics and Related Research 471: 2383–99. 11

Malcolm TI, Robinson LD, Klika AK, et al. 2016. Predictors of Staphylococcus aureus colonization and results after decolonization. Interdisciplinary Perspectives on Infectious Diseases 2016: 1–8.


3. Meta-analysis findings

The Commission contracted the Royal Australasian College of Surgeons to conduct a

systematic literature review and meta-analysis pertaining to anti-staphylococcal bundles

published through to the end of 2015. The anti-staphylococcal bundle was defined as skin

and/or nasal decolonisation. This work was built on the Schweizer et al12 meta-analysis (the

base reference) by identifying appropriate literature published between January 2011 and

December 2015. The methods and reporting have been aligned with those used in the base

reference.

Please review the meta-analysis summary in the attached PDF document (Appendix 2) and the summary of bundle components from the meta-analysis (Appendix 3). The full meta-analysis report is available on request. The impact of S. aureus screening itself was not a research question of the meta-analysis. Nevertheless, previous systematic reviews have already established the effectiveness of the intervention based on pre-surgery S. aureus screening in preventing SSIs.13,14 The choice between combining screening with a personalised treatment regimen versus universal application of a decolonisation intervention to reduce the occurrence of SSIs will depend on local factors – for example, how the patient’s clinical pathway is organised and national antibiotic susceptibility profiles.

12

Schweizer M, Perencevich E, McDanel J, et al. 2013. 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 346: f2743. 13

Chen AF, Wessel CB, Rao N. 2013. Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections. Clinical Orthopaedics and Related Research 471(7): 2383–99. 14

Rodriguez-Merchan EC. 2014. Screening and decolonization of MRSA among joint arthroplasty patients: Efficacy, cost-effectiveness and durability. Journal of Acute Disease 3(3): 218–20.


4. Proposed bundle

As a result of the meta-analysis findings, the Commission’s Strategic Infection Prevention and Control Advisory Group (SIPCAG) along with the orthopaedic and cardiac expert faculty groups recommended that there was enough evidence to support further discussion with the sector on the benefits and components of an anti-staphylococcal bundle to reduce S. aureus SSIs in orthopaedic and cardiac surgical patients.

The current processes used in New Zealand vary among DHBs. For example:

Some DHBs pre-screen their orthopaedic and cardiac surgical patients for MRSA but not

for methicillin-sensitive Staphylococcus aureus (MSSA). Confirmed MRSA-colonised

patients are then decolonised.

Some DHBs implement skin decolonisation but not nasal decolonisation.

Some DHBs leave the preoperative screening and decolonisation practice up to the

discretion of the surgeon.

Most DHBs have no preoperative screening or decolonisation protocols.

Introducing a standardised process would reduce the risk of staphylococcal SSI and provide an additional way to improve patient safety. The Commission would work with the sector to develop a bundle comprising either targeted or universal decolonisation. The two approaches being considered are:

Targeted decolonisation: Surgical patients would be screened for S. aureus colonisation

and decolonised if positive.

Universal decolonisation: No screening would occur; all patients would receive the same

decolonisation bundle regardless of colonisation.

If targeted decolonisation was chosen as the national approach, specific screening methods and decolonisation agents would be recommended. If universal decolonisation was chosen, specific decolonisation agents would be recommended.

The meta-analysis concluded that ‘S. aureus SSIs in orthopaedic and cardiac surgeries can be effectively reduced with an appropriate and standardised bundle of prophylactic antibiotics and nasal and skin decolonisation’.


5. Benefits and risks

Benefits:

A standardised process for reducing the risk of staphylococcal SSI will reduce harm and

improve patient safety.

Patients can pro-actively participate in reducing their risk of SSI following surgery.

Universal decolonisation may be more cost-effective and logistically easier than

implementing a screening protocol (refer to Appendices 4, 5 and 6).

The cost of nasal and skin bundle components would be in the order of $15, and there

would be a saving of ~$40,000 for each SSI prevented (refer to Appendices 4 & 5).

The dollar saving of the bundle would be ~14:1 (saved to spent) for a 50% reduction in

all SSIs, an optimistic assumption (refer Appendix 5, Table 1, row 2).

The dollar saving of the bundle would be ~2:1 for only a 30% reduction in S. aureus

SSIs, a conservative assumption (refer to Appendix 5, Table 1, row 8).

Risks:

Logistical complexities of preoperative screening patients (targeted decolonisation) could

lead to gaps in patients being screened and hence decolonised (please refer to more

detailed issues related to preoperative screening for S. aureus in Appendix 6).

If patient education is not implemented correctly, this process may not result in

decreased SSI risk.

Universal decolonisation may compromise the ability to watch for the emergence of new

clones of S. aureus, contribute to mupirocin resistance if mupirocin is used in the bundle,

and prevent the adjustment of surgical prophylaxis for MRSA (eg, vancomycin or other

glycopeptide added to β-lactam agent). Refer to Appendix 7 for mupirocin and fusidic

acid resistance patterns in New Zealand.

In the effort to eliminate S. aureus carriage, there is the potential risk of adverse events.

Preoperative screening for intranasal carriage does not capture 100% of the S. aureus

carriers. Although the anterior nares is the most frequent site of carriage for both MRSA

and MSSA, only about 74% of people that are colonised with MRSA carry it in their nasal

cavity. Evidence indicates this percentage may be less for MSSA carriers. There are

other locations on the body (eg, axillae, groin, perineum) that an S. aureus carrier can be

colonised.


6. Your feedback requested

Please provide your feedback to the following questions. These questions below relate to an

anti-staphylococcal bundle for elective cardiac and hip and knee joint replacement

procedures with the bundle being used the day before and day of surgery. We also welcome

general feedback related to the introduction of such a bundle.

Please provide your feedback to the following questions via survey monkey link:

https://www.surveymonkey.com/r/anti-staphylococcalbundle

1. Do you think there would be benefit in adding an anti-staphylococcal bundle to the existing interventions associated with the Surgical Site Infection Improvement (SSII) programme? Y / N

Comments:

2. Based on logistics and simplicity, we recommend universal decolonisation (decolonise all orthopaedic and cardiac surgical patients with topical nasal and skin agents). Do you agree? Y / N

Comments:

3. Based on potential resistance with mupirocin use, we recommend povidone-iodine for nasal decolonisation as our first choice. Mupirocin is considered an alternative agent. Do you agree? Y / N

Comments:

4. Based on logistics and simplicity, we recommend the chosen nasal preparation is administered twice the day before and once the morning of surgery. Do you agree? Y / N

Comments:

5. Based on logistics and simplicity, our first choice for skin decolonisation is chlorhexidine (wash or wipes) administered twice the day before and once the morning of surgery. Triclosan would be recommended as a second choice for chlorhexidine allergy. Do you agree? Y / N

Comments:

6. Based on the meta-analysis, we recommend that any bundle should consist of both nasal and skin components. Do you agree? Y / N

Comments:

7. Other comments?

https://www.surveymonkey.com/r/anti-staphylococcalbundle


Appendix 1: Orthopaedic SSIs caused by staphylococci: March

2013 to March 2016

Between March 2013 and March 2016 there were 340 SSIs.

Out of 328 isolates, thirty-six SSI cases (12%) grew polymicrobial cultures.

The SSI cases in the table below were due only to staphylococcal species – that is, all

mixed cultures with staphylococci were ignored and only SSIs with a pure growth of

staphylococci are included in the table below.

SSI type Superficial Deep and organ space

Total (%)

n 118 222 340

Staphylococcus aureus 39 68 107

% 33% 31% 31%

Coagulase-negative staphylococci

6 42 48

% 5% 19% 14%

All staphylococci 45 110 155

% 38% 50% 46%

Overall, 46% of all SSIs were due to staphylococci.

S. aureus caused 31% of all SSIs.

Coagulase-negative staphylococci caused 14% of all SSIs, including 19% of deep and

organ space SSIs.


Appendix 2: Overview of meta-analysis of S. aureus SSI prevention

in orthopaedic and cardiac surgery


PICO criteria


The full meta-analysis report is available on request. Please email Nikki Grae at

[email protected]


Appendix 3: Summary of bundle components from the papers in

meta-analysis

Of twenty-five reports, all used nasal intervention and 18 also used skin component.

Nose agents:

Twenty-three used mupirocin, three used povidone-iodine (two also used mupirocin),

one used chlorhexidine.

For mupirocin: 13 described frequency as BD (twice a day), one as TDS (three times a

day), one as ×2 night before and ×1 morning of surgery. Rest no comment. Duration

mentioned by 21; 11 were ≥ 5 days, and 8 were day before and day of surgery.

Most common was BD for 5 days (9 studies). Almost the same for day before and day of

group, (8 studies).

Five studies carried on post-op for 2–5 days.

Nasal povidone-iodine was applied the day of surgery in two of the three studies using

it.15,16 The other paper no information provided.

Skin agents:

Chlorhexidine (CHX) used for 15 of the 18 studies with a skin component, 14 as sole

agent.

Preparations: shower/(soap) = 3, bath = 1, soap = 9, rest = not stated.

Most used it once a day.

Duration 3–5 days 9 studies, 5 with night before and day of surgery.

Triclosan used in two studies, povidone-iodine soap in one.

Nasal povidone-iodine vs nasal mupirocin study15

Spinal fusion or arthroplasty patients, total = 1697 (82% arthroplasty), 1539 on per protocol

basis.

All patients had six 2% CHX wipes on specific body surfaces from chin to toes the evening

before and morning of surgery. End point = deep SSI within 90 days. Centers for Disease

Control and Prevention (CDC) definitions used.

Nasal regimens:

Nasal mupirocin 2%, BD, 5 days before surgery

Nasal solution povidone-iodine 5%, two 30-second applications to each nostril within 2

hours of surgery.

15

Phillips M, Rosenberg A, Shopsin B, et al. 2014. Preventing surgical site infections: a randomised, open-label trial of nasal mupirocin ointment and nasal povidone iodine solution. Infection Control and Hospital Epidemiology 35: 826–32. 16

Bebko SP, Green DM, Awad SS. 2015. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopaedic surgery with hardware implantation. JAMA Surgery 150: 390–95.


Results:15

Mupirocin Povidone-iodine P value

Intention to treat protocol

Any deep SSI 14/855 (1.6%) 6/842 (0.7%) 0.1

S. aureus SSI 5/855 (0.6%) 1/842 (0.1%) 0.2

Per protocol

S. aureus 5/763 (0.7%) 0/776 0.03

Adverse events

Nasal effect, discontinuation 0 1

CHX wipe skin event (rash/itch) 1.2% 1.5% 0.54

Any treatment symptom 8.9% 1.8% <0.0001

Patient perception

Rx important to reduce SSI 57% 60%

Application ‘unpleasant’ 38% 4% <0.0001

While it would seem sensible to apply the nasal preparation at least at the same start time as

any skin decontamination method, both the nasal solution papers on the meta-analysis only

used the nasal application the morning of surgery.15,16

We recommend: CHX starting the day before (twice a day) and the morning of surgery.

Nasal povidone-iodine to start the day before as well, with further application(s) morning of

surgery.

Mupirocin is an alternative nose agent. Triclosan wash is an alternative skin agent for

patients with CHX allergy.

Reasons to favour nasal povidone-iodine over nasal mupirocin:

New Zealand resistance rates to fusidic acid and mupirocin among local staphylococci

increased mupirocin resistance when it is used in ICU settings

no reported resistance to iodine

trial data showing positive effect for povidone-iodine with use limited to just the day of

surgery

most mupirocin data relates to use for many days, although some has been day before

and day of surgery

better patient acceptance in Phillips et al study15 (see above)

fewer overall side effect symptoms in Phillips et al study15 (see above)

cost

there is a current supply issue with mupirocin, which could occur in the future.


Appendix 4: SSI bundle costing

Agent type Agent name Topical preparations

Pricing Estimate Comments

Nasal decolonisation agents

Mupirocin Ointment 2% (22 g)

$9.34 NB: Current shortage, section 29 of Medicines Act

Nasal ointment 2% (3 g)

Approved Price (AP)

$43.99 section 29 of Medicines Act

Povidone-iodine

Ointment 10% (25 g)

National Price (NP)

$3.27

Fusidic acid Ointment 2% (15 g)

NP $3.45

Cream 2% (15 g)

NP $2.52

Skin decolonisation agents

Chlorhexidine Cream 1% (50 g)

NP $1.21

M/Wash 0.2% (200 mL)

NP $2.57

Lotion 1% (200 mL)

NP $2.98

Solution 4% (50 mL)

NP $1.86

Solution 4% (500 mL)

Community NP

$3.98 Not listed HML*

Community use restricted to dialysis patients

Solution 5% (500mL)

NP $15.50

Wipes 2%

$184/carton

$3.83/pack

48 packs/carton. Four wipes a pack. One pack for whole body ‘wipe’.

Not listed HML.*

Scrub brush 4%

Triclosan Solution 1% (500 mL)

Community NP

$4.50 Not listed HML*

Community use restricted to MRSA decolonisation

* Hospital medicines list. We have initiated a request to get these onto the list so hospitals can access

them.

NB: At present there would be cost and availability issues for some possible bundle

components for scripts to be filled in the community. It will take some time for these to be

resolved with PHARMAC.


In the meantime DHBs would be able to dispense the chosen bundle components, with clear

instructions, to patients while they are in the hospital – for example, at pre-admission clinic.

This would remove any cost as a barrier to patients and allow focused discussion with the

patient on how they can contribute to reducing their risk for SSI.


Appendix 5: Back of envelope cost–benefit analysis of an anti-

staph bundle in New Zealand

Meta-analysis of observational studies showed ~50% reduction in ‘all cause’ SSIs (slides

10 and 12, Appendix 2).

Also showed ~50% reduction in S. aureus SSIs (slides 11 and 12, Appendix 2).

To March 2016: 28,768 orthopaedic procedures, 340 SSIs.

155 SSIs due to pure growths of staphylococci; 107 S. aureus, rest other staphylococci.

67 deep and organ space SSIs due to pure growth of S. aureus.

Excess cost of orthopaedic SSI = $40,000, excess length of stay (LOS) = 42 days.17

Cost of S. aureus screen likely to be at least $20.

Assume a conservative treatment bundle cost – that is, nasal mupirocin (~ $9) and CHX

body wash (0.5L = ~$6). Total = $15.

Table 1 below assumes increasingly conservative clinical benefit of a bundle.

No allowance made for reduction in deaths related to SSIs.

M = $1,000,000.

Px = prophylaxis bundle.

Screening cost: 28,768 × $20 = $0.576M.

Treatment cost, all patients: 28,768 × $15 = $0.432M.

Treatment cost after screening, assume ~30% positive: 28,768 × 0.3 × $15 = $0.130M.

‘Screen and treat’ bundle cost = $0.576M + $0.130M = $0.706M.

Cost difference between ‘screen and Px’ vs. ‘universal Px’ = $0.274M.

Additional cost only calculated for first assumption in table.

Assuming 40–50% reduction in all-cause SSIs predicts the most saving, ~$5–6M.

Assuming 40–50% reduction in only staphylococcal SSIs there is still considerable saving,

~$2–2.6M.

Assuming 30–40% reduction in S. aureus SSIs only, saving $0.8–1.2M.

17

Gow N, McGuinness C, Morris AJ, et al. 2016. Excess cost associated with primary hip and knee joint arthroplasty surgical site infection: a driver to support investment in quality improvement strategies to reduce infection rates. New Zealand Medical Journal 129(1432): 51–8. URL: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1432-1-april-2016/6848 (accessed 26 September 2016).

https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1432-1-april-2016/6848

https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2016/vol-129-no-1432-1-april-2016/6848


Table 1: Cost–benefit analysis of bundle based on increasingly conservative

assumptions

Assumption, bundle prevents

Total SSIs

SSIs prevented

Cost saved

Bundle Cost of bundle

Saving Bed days saved

50% all SSIs 340 170 $6.7M Screen and Px if positive

$0.706 $5.994M 7098

50% all SSIs 340 170 $6.7M No screen, universal Px

$0.432 $6.268M 7098

50% all staph SSIs 155 77 $3.08M No screen, universal Px

$0.432 $2.648M 3234

40% all SSIs 340 136 $5.4M No screen, universal Px

$0.432 $4.968 5670

40% all staph SSIs 155 62 $2.44M No screen, universal Px

$0.432 $2.008M 2562

40% S. aureus SSIs only

107 42 $1.68M No screen, universal Px

$0.432 $1.248M 1764

40% S. aureus deep and organ space SSIs only


$0.432 $0.648M 1134

30% S. aureus SSIs


$0.432 $0.848M 1344

30% S. aureus SSIs deep and organ space only


$0.432 $0.368M 840

20% S. aureus SSIs deep and organ space only


$0.432 $0.088M 546

Px = prophylaxis bundle


Appendix 6: Issues relating to screening for S. aureus carriage

While several studies included in the meta-analysis performed screening and either applied

the bundle to carriers or stopped the bundle if cultures were negative, there are several

logistical and theoretical issues that need to be considered.

A single nose swab does not detect all carriers. People may have carriage at other sites

or ‘low count’ colonisation in the nose. That said, the risk of developing S. aureus

infection may be lower in those that are ‘missed’ in a single nasal swab.

Decisions would need to be made if swabbing was undertaken in the patient pathway.

For example:

– Swab collected at outpatients or pre-admission clinic?

– Self-swab or staff collect?

– Timing in relation to operation date to allow testing and reporting before admission.

– Which laboratory does swab go to?

– What method (plate/broth/polymerase chain reaction (PCR)) is used in the laboratory

to detect carriage?

– Screening could be a significant increase in specimen processing (plating or PCR)

for the lab.

– Who pays for swab? For many laboratory contracts this would need to be negotiated

with the laboratory service provider.

– Where does the result go to get actioned – ward/clinic/GP/surgeon?

– How is theatre (preoperative holding area) notified if positive for MRSA to ensure

vancomycin is added to prophylaxis with increased administration time?

– Who responds to positive screen results?

– How would script or ‘bundle package’ be sent to patients?

– How is use of bundle explained to patient?

– How is compliance measured on admission?

– For confirmed positive MRSA carriers, would there be a recommendation of delaying

procedure if decolonisation could not be completed prior to scheduled surgery date?

– Surgery may be delayed, so what is an acceptable time between screening and

having the procedure performed (eg, weeks or months)?

Screening would detect MRSA carriage and allow vancomycin to be added to surgical

prophylaxis – ~10% of S. aureus in New Zealand is MRSA.

It is possible that any bundle aimed at S. aureus may also have a beneficial effect on

reducing SSIs due to coagulase-negative staphylococci. Applying the bundle to only

S. aureus carriers would prevent any beneficial effect on other staphylococci.

The cost of a screen is likely to be in the order of $20–25.

On balance it is recommended that screening should not be part of any anti-staph

patient care bundle.


Appendix 7: Susceptibility of staphylococci in New Zealand

Local resistance patterns are relevant when making choices/recommendations for

components in an ‘anti-staph’ bundle.

The best reference for New Zealand-wide data is the recent Institute of Environmental

Science and Research (ESR) report on susceptibility of S. aureus in New Zealand.20

For Table 2, the resistant (R) percentage does not include intermediate strains.

Table 2: Staphylococcal resistance rates for fusidic acid and mupirocin in New

Zealand

MRSA MSSA S. epidermidis Coag-neg

staphs

Where Year % R

fusidic acid

% R

mupirocin

% R

fusidic acid

% R

mupirocin

% R

fusidic acid

% R

fusidic acid

Auckland

LabPlus18

2015 49%

(n=573)

8%

(n=573)

19%

(n=3758)

8%

(n=3758)

60%

(n=533)

19%

(n=313)

Auckland

Labtests Auckland

19

2015 50%

(n=3988)

8%

(n=3988)

26%

(n=27,559)

12%

(n=27,559)

National20

(weighted data)

2014 58%

(n=123)

4%

(n=123)

22%

(n=1255)

9%

(n=1255)

We are unaware of mupirocin susceptibility data for coagulase-negative staphylococci in

New Zealand.

Reduced susceptibility to chlorhexidine is known to occur. The most common and studied

mechanism of reduced susceptibility is the presence of efflux-pump(s), encoded by qac

genes (qacA/B, etc). Approximately 7% of isolates in the ESR survey20 were qacA/B positive

18

LabPLUS, Auckland City Hospital. 2016. Summary of antimicrobial susceptibility test results: 2015. URL: http://www.labplus.co.nz/assets/Uploads/2015-Gram-positive-antimicrobial-report.pdf (accessed 26 September 2016). 19

Labtests Auckland. 2016. Cumulative antimicrobial susceptibility report – Auckland 2015. URL: http://www.labtests.co.nz/images/Referrers/Information/AST-2015-Table.pdf (accessed 26 September 2016). 20

Heffernan H, Bakker S, Woodhouse R, et al. 2016. Demographics, antimicrobial susceptibility and molecular epidemiology of Staphylococcus aureus in New Zealand. URL: https://surv.esr.cri.nz/PDF_surveillance/Antimicrobial/Staph/2014Saureussurveyreport.pdf (accessed 26 September 2016).

http://www.labplus.co.nz/assets/Uploads/2015-Gram-positive-antimicrobial-report.pdf

http://www.labtests.co.nz/images/Referrers/Information/AST-2015-Table.pdf

https://surv.esr.cri.nz/PDF_surveillance/Antimicrobial/Staph/2014Saureussurveyreport.pdf


(Dr D. Williamson, personal communication). The relationship between qac gene carriage,

phenotypic reduced susceptibility and clinical efficacy is not clear.21

Resistance to iodine-containing preparations is not known to occur.

Based on susceptibility data, fusidic acid should not be used as part of an anti-staph bundle.

Mupirocin resistance is not rare, and its use may reduce the efficacy of any bundle which

includes it.

We recommend that a povidone-iodine preparation be used as the nasal component of an

anti-staph bundle. Mupirocin is an alternative agent and should be used if there is a concern

about allergy to iodine.

21

Horner C, Mawer D, Wilcox M. 2012. Reduced susceptibility to chlorhexidine in staphylococci: is it increasing and does it matter? Journal of Antimicrobial Chemotherapy 67(11): 2547–59. DOI:10.1093/jac/dks284.

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