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• W2080161356 abstract "Surgical site infection (SSI) is increasingly recognised as a measure of the quality of patient care by surgeons, infection control practitioners, health planners and the public. There is increasing pressure to compare SSI rates between surgeons, institutions and countries. For this to be meaningful, data must be standardised and must include post-discharge surveillance (PDS) as many superficial SSIs do not present to the original institution. Further work is required to determine the best method of conducting PDS. In 2008 two important documents on SSI were published from the Society for Healthcare Epidemiology of America/The Infectious Disease Society of America and the National Institute for Health and Clincal Excellence, UK. Both emphasise key aspects during the preoperative, operative and postoperative phases of patient care. In addition to effective interventions known to be important for some time, e.g. not shaving the surgical site until the day of the procedure, there is increasing emphasis on physiological parameters, e.g. blood glucose concentrations, oxygen tensions and body temperature. Laparoscopic procedures are increasingly associated with reduced SSI rates, and the screening and decontamination of meticillin-resistant Staphylococcus aureus carriers is effective for certain surgical procedures but has to be balanced by cost and the risk of mupirocin resistance. Finally, there is a need to convert theory into practice by the rigorous application of SSI healthcare bundles. Recent studies suggest that, with a multidisciplinary approach, simple measures can be effective in reducing SSI rates. Surgical site infection (SSI) is increasingly recognised as a measure of the quality of patient care by surgeons, infection control practitioners, health planners and the public. There is increasing pressure to compare SSI rates between surgeons, institutions and countries. For this to be meaningful, data must be standardised and must include post-discharge surveillance (PDS) as many superficial SSIs do not present to the original institution. Further work is required to determine the best method of conducting PDS. In 2008 two important documents on SSI were published from the Society for Healthcare Epidemiology of America/The Infectious Disease Society of America and the National Institute for Health and Clincal Excellence, UK. Both emphasise key aspects during the preoperative, operative and postoperative phases of patient care. In addition to effective interventions known to be important for some time, e.g. not shaving the surgical site until the day of the procedure, there is increasing emphasis on physiological parameters, e.g. blood glucose concentrations, oxygen tensions and body temperature. Laparoscopic procedures are increasingly associated with reduced SSI rates, and the screening and decontamination of meticillin-resistant Staphylococcus aureus carriers is effective for certain surgical procedures but has to be balanced by cost and the risk of mupirocin resistance. Finally, there is a need to convert theory into practice by the rigorous application of SSI healthcare bundles. Recent studies suggest that, with a multidisciplinary approach, simple measures can be effective in reducing SSI rates. IntroductionRecent years have seen an increasing emphasis on the importance of surgical site infection (SSI) from the perspective of the surgeon, infection prevention and control practitioners, health administrators, managers and patients. While some healthcare-associated infections (HCAIs) such as bloodstream infections are more likely to be associated with life-threatening illness or even death, SSI remains among the commonest infections occurring in acute hospitals.In a survey of 75 694 patients in England, Wales, Northern Ireland and the Republic of Ireland, the overall prevalence of HCAI was 7.59%, with SSI accounting for 14.5% of these infections.1Smyth E.T.M. McIllvenny G. Enstone J.E. et al.Four country healthcare associated infection prevalence survey 2006: overview of the results.J Hosp Infect. 2008; 69: 230-248Abstract Full Text Full Text PDF PubMed Scopus (235) Google Scholar, 2Humphreys H. Newcombe R.G. Enstone J. et al.Four country healthcare associated infection prevalence survey 2006: risk factor analysis.J Hosp Infect. 2008; 69: 249-257Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The surveillance of some or all SSIs is conducted in many hospitals as part of routine surveillance and as a measure of patient safety. For a period of 15 years from 1982 to 1997, 59 335 surgical sites were surveyed in a 600-bed hospital with an overall SSI rate of 4.5%, and for clean surgery 2.4%, with little change in rates during that period.3Creamer E. Cunney R.J. Humpreys H. Smyth E.G. Sixteen year's surveillance of surgical sites in an Irish acute-care hospital.Infect Control Hosp Epidemiol. 2002; 23: 36-40Crossref PubMed Scopus (10) Google ScholarThe significance of SSI and its prevention to surgeons carrying out procedures has increased as they realise that this is a measure of their effectiveness. Many surgeons rightly consider that the most critical factor in the prevention of SSI, although difficult to scientifically quantify, is the sound judgement and proper technique of the surgeon and his/her team, as well as the general health of the patient.4Nichols R.L. Preventing surgical site infections: a surgeon's perspective.Emerg Infect Dis. 2001; 7: 220-224Crossref PubMed Scopus (173) Google Scholar It is important to ensure that the actual surgical procedure is successful, e.g. complete removal of a tumour, and that preventible adverse consequences arising from not adequately addressing infection prevention are addressed.Quality iniatives taken by surgeons in collaboration with others are bearing fruit in highlighting the issues and possible interventions. As part of the American College of Surgeons Standard National Surgical Quality Improvement Programme (NSQIP), a survey of 117 private sector hosptials was undertaken to identify low and high outliers in terms of SSI prevention.5Campbell D.A. Henderson W.G. Englesbe M.J. et al.Surgical site infection prevention: the importance of operative duration and blood transfusion – results of the first American College of Surgeons–National Surgical Quality Improvment Program Best Practices Initiative.J Am Coll Surg. 2008; 207: 810-820Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar High outliers (increased infection rates) were assoicated with higher numbers of trainees, longer operations, and low haemoglobin levels in operated patients; low outliers had a policy of minimising operating-room traffic.5Campbell D.A. Henderson W.G. Englesbe M.J. et al.Surgical site infection prevention: the importance of operative duration and blood transfusion – results of the first American College of Surgeons–National Surgical Quality Improvment Program Best Practices Initiative.J Am Coll Surg. 2008; 207: 810-820Abstract Full Text Full Text PDF PubMed Scopus (183) Google ScholarApart from the obvious morbidity and sometimes mortality that follows SSI, it is increasingly recognised that there is a significant cost to the healthcare system such as prolonged hospital stay as well as the cost to society in disability payments while out of work and loss of income tax revenue. An example of the healthcare costs is described in a case–control study of SSI following coronary artery bypass surgery in Australia between 1996 and 1998 in which 125 patients developed SSI; the mean excess healthcare cost attributable to SSI was $AU12,419 per case.6Jenney A.W.J. Harrington G.A. Russo P.L. Spelman D.W. Cost of surgical site infections following coronary artery bypass surgery.Aust N Z J Surg. 2001; 71: 662-664Crossref Scopus (92) Google ScholarSSI rates are increasingly seen as an example of a performance indicator of the quality of healthcare. Changes are taking place in some countries leading to the public reporting of HCAI, including SSI rates.7Humphreys H. Cunney R. Performance indicators and the public reporting of healthcare-associated infection rates.Clin Microbiol Infect. 2008; 14: 892-894Crossref PubMed Scopus (11) Google Scholar, 8McKibben L. Horan T. Tokars J.I. et al.Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee.Am J Infect Control. 2005; 33: 217-226Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar Although there are some logistical difficulties in ensuring that rates are truly comparable, it is likely that the future will see patients having access to the SSI rate of their local hospital before admission for elective surgery. In North America, this aspect of what could be described as ‘healthcare consumerism’ has led to major initiatives involving healthcare professionals, patient groups and others, to try to significantly improve the quality of care by focusing on those aspects that are amenable to prevention, thus aiming to reduce infection rates and produce better patient care.9Bratzler D.W. Hunt D.R. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.Clin Infect Dis. 2006; 43: 322-330Crossref PubMed Scopus (441) Google Scholar In this review, some aspects of surveillance and recent issues in SSI prevention are discussed.Measuring the SSI rateThe details of techniques used for the surveillance of SSI are beyond the scope of this review, nevertheless it is essential that standardised definitions are used, e.g. classifying infections into superficial, incisional, deep incisional and organ/space, and that allowance is made for risk factors, especially when infection rates are likely to be compared between one surgeon or one institution and another.10National Institute for Health and Clinical Excellence Surgical site infection, prevention and treatment of surgical site infection. National Collaborating Centre for Women's and Children's Health, 2008Google Scholar, 11Anderson D.J. Kaye K.S. Classen D. et al.Strategies to prevent surgical site infections in acute care hospitals.Infect Control Hosp Epidemiol. 2008; 29: S51-S61Crossref PubMed Scopus (320) Google Scholar This must be done accurately and allow for changes in healthcare such as those resulting in shorter acute hospital stay, leading to many infections being diagnosed either in the outpatients or in the community. This emphasises the importance of post-discharge surveillance (PDS). Although there are a number of options for PDS, existing research does not appear to have identified a valid, reliable, practical and universally agreed method for PDS.12Petherick E.S. Dalton J.E. Moore P.J. Cullum N. Methods for identifying surgical wound infection after discharge from hospital: a systematic review.BMC Infect Dis. 2006; 6: 170Crossref PubMed Scopus (113) Google ScholarWhitby and colleagues in Queensland, Australia attempted to improve the reliability of PDS through patient self-determination and a programme of educating patients on SSI.13Whitby M. McLaws M.-L. Doidge S. Collopy B. Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?.J Hosp Infect. 2007; 66: 237-242Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The positive predictive value for a correct diagnosis was 65.2% for the educated group compared with 83.3% for the non-educated patient group, and the authors concluded that pre-discharge education resulted in patients overdiagnosing SSI.13Whitby M. McLaws M.-L. Doidge S. Collopy B. Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?.J Hosp Infect. 2007; 66: 237-242Abstract Full Text Full Text PDF PubMed Scopus (18) Google ScholarPDS is particularly important for superficial incisional SSI, which may not be serious enough to warrant re-admission to hospital. For example, in a survey in Finland of orthopaedic SSI, 86% of SSIs detected after hospital discharge were superficial.14Huotari K. Lyytikäinen O. Impact of postdischarge surveillance on the rate of surgical site infection after orthopaedic surgery.Infect Control Hosp Epidemiol. 2006; 27: 1324-1329Crossref PubMed Scopus (65) Google Scholar Data derived from 12 885 operations in Scotland yielded a statistically higher SSI rate when PDS was performed (6.34% compared with 2.61%) and the authors concluded that a procedure-specific approach was required with direct observation of patients.15Reilly J. Allardice G. Bruce J. Hill R. McCoubrey J. Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland.Infect Control Hosp Epidemiol. 2006; 27: 1318-1323Crossref PubMed Scopus (67) Google Scholar In The Netherlands, a national nosocomial surveillance network has been collecting data on HCAI for some years. SSI rates were determined according to different PDS methods for surgical procedures performed in 62 hospitals.16Manniën J. Wille J.C. Snoeren R.L.L.M. van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands.Infect Control Hosp Epidemiol. 2006; 27: 809-816Crossref PubMed Scopus (70) Google Scholar Recommended PDS methods, e.g. direct observation by the surgeon, were compared with passive surveillance, e.g. patients re-presenting to the hospital. Recommended compared with passive surveillance methods detected a higher SSI rate, 3.7% compared with 3.1%.16Manniën J. Wille J.C. Snoeren R.L.L.M. van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands.Infect Control Hosp Epidemiol. 2006; 27: 809-816Crossref PubMed Scopus (70) Google ScholarIt is universally acknowledged that PDS is essential in accurately determining the SSI rate, but there is a need for consensus as to how best this can be achieved while taking into account limited resources.Preventing SSIApproaches to the prevention and control of SSI have evolved over many years and traditionally have been classified into those interventions before surgery, during surgery and after surgery. However, prevention must be underpinned by a knowledge and understanding of the microbial pathogenesis, and the importance of surveillance. Much of the advice from the Hospital Infection Control Practices Advisory Committee (HICPAC) from North America on SSI prevention is derived from practice and custom, rather than rigorous scientific studies such as randomised controlled trials, but practice, custom and even ritual, continue to influence approaches to prevention.17Mangram A.J. Horan T.C. Pearson M.L. Silver L.C. Jarvis W.R. Guideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol. 1999; 20: 247-280Crossref Scopus (1761) Google ScholarIn 2008 two important documents were published that synthesised and presented clearly many of the important issues pertaining to the prevention of SSI. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America produced recommendations on HCAI including SSI, addressing surveillance methods, interventions to actively prevent SSI and approaches to monitoring the implementation of those strategies.11Anderson D.J. Kaye K.S. Classen D. et al.Strategies to prevent surgical site infections in acute care hospitals.Infect Control Hosp Epidemiol. 2008; 29: S51-S61Crossref PubMed Scopus (320) Google Scholar In the UK, the National Institute for Health and Clinical Excellence published a document on the prevention and treatment of SSI which emerged after an extensive review of the literature and a wide consultation exercise.10National Institute for Health and Clinical Excellence Surgical site infection, prevention and treatment of surgical site infection. National Collaborating Centre for Women's and Children's Health, 2008Google Scholar Both documents repesent an impressive body of literature on SSI but combine this with practical and feasible advice about prevention; both emphasise the importance of education and the identification of risk factors for SSI. Some of the issues from both documents are outlined in Table I. Some are discussed below in terms of the evidence and what should be incorporated into current practice.Table IMajor headings and some factors in preventing surgical site infection from recent UK and North American guidelinesNICEaAdapted from reference 10.SHEA/IDSAbSociety for Healthcare Epidemiology of America/Infectious Diseases Society of America (adapted from reference 11).Preoperative phaseSurgical Care Improvement Project Patient showering and hair removal Proper hair removal Patient and staff theatre wear Controlling blood glucose Movement to and from theatre area Maintain normothermia Nasal decontamination (do not use mupirocin routinely)Infrastructure Mechanical bowel preparation (not routine) Trained personnel Patient and staff jewellery Education Antibiotic prophylaxis (which patients, when and number of doses)Computer-assisted decision support and automated remindersIntraoperative phaseAntimicrobial prophylaxis Hand decontaminationMeasure and provide feedback on process measures, e.g. hair removal Incise drapesAccountabilityGowns and gloves Chief executive responsible for support Antiseptic skin preparation and diathermy Senior management ensures adequate personnel and perform job responsibilities Patient homeostasis (oxygenation, normothermia, etc.) Healthcare workers responsible for their practices Wound irrigation and dressingsNon-routine approaches Antiseptics before closureVancomycin not routine for antimicrobial prophylaxisPostoperative phase Don't delay surgery for parenteral nutrition DressingsUnresolved issuesPostoperative cleansing of surgical sitePreoperative bathing with chlorhexidine Topical agents (not indicated) Positive screening for, and decolonisation of, MRSA Antibiotic treatment and debridement for SSI Supplemental oxygenation for colorectal procedures Specialist wound care services Maintaining normothermia after colorectal surgeryMRSA, meticillin-resistant Staphylococcus aureus; SSI, surgical site infection.a Adapted from reference 10.b Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (adapted from reference 11Anderson D.J. Kaye K.S. Classen D. et al.Strategies to prevent surgical site infections in acute care hospitals.Infect Control Hosp Epidemiol. 2008; 29: S51-S61Crossref PubMed Scopus (320) Google Scholar). Open table in a new tab Hand hygiene and the surgical scrubHand hygiene is regarded as one of the key components in any infection prevention strategy. For many years, the traditional surgical scrub where the surgeon ensures that hands, nails and parts of the forearm are lathered and scrubbed has been standard practice. However, surgeons themselves accept that their practice, both in the operating theatre and outside, has often been suboptimal; 90% compliance is not sufficient.18Gawande A. On washing hands.N Engl J Med. 2004; 350: 1283-1286Crossref PubMed Scopus (48) Google Scholar Recent evidence suggests that the traditional ritual of scrubbing can be replaced by a less lengthy and less ritualistic procedure. In a study involving six surgical services and 4387 consecutive patients who underwent clean and clean-contaminated surgery earlier this decade, there was no difference in the SSI rate, whether the surgeon used the hand-rubbing protocol with 75% aqueous alcohol or a hand-scrubbing protocol with povidone-iodine or chlorhexidine.19Parienti J.J. Thibon P. Heller R. et al.Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates. A randomised equivalence study.J Am Med Assoc. 2002; 288: 722-727Crossref Scopus (243) Google Scholar Furthermore, the alcohol solution was better tolerated and associated with improved compliance.Physiological parametersTissue hypoxia leads to necrosis and is often followed by infection. High blood glucose levels, such as occur in patients with diabetes mellitus for example, are also associated with increased risks of infection. It is logical to assume that normalising these will assist in the prevention of SSI, and recent studies have supported this. Gottrup has emphasised that the decisive period for the development of SSI is during surgery and the first few hours thereafter; consequently, the physiological status of the patient at that time is crucial.20Gottrup F. Prevention of surgical-wound infections.N Engl J Med. 2000; 342: 202-204Crossref PubMed Scopus (57) Google Scholar A higher fraction of inspired oxygen (80% compared with 30%) was associated with a 39% lower risk of SSI in a randomised controlled trial of 300 patients.21Belda F.J. Aguilera L. García de la Asunción J. et al.Supplemental perioperative oxygen and the risk of surgical wound infection. A randomised controlled trial.J Am Med Assoc. 2005; 294: 2035-2042Crossref PubMed Scopus (409) Google Scholar It is believed that the mechanism of action is by more effective neutrophil killing of potential pathogens.22Alan D.B. Maguire J.J. Mahdavian M. et al.Wound hypoxia and acidosis limit neutrophil bacteria killing mechanisms.Arch Surg. 1997; 132: 991-996Crossref PubMed Scopus (380) Google ScholarIn a case-controlled study of 260 patients undergoing mastectomy, variables associated with SSI included high blood glucose levels.23Vilar-Compte D. de Iturbe I. Martín-Onraet A. et al.Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy.Am J Infect Control. 2008; 36: 192-198Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Similarly, in an assessment of risk factors for SSI after surgery for hepato-biliary pancreatic cancer, poor blood glucose levels were associated with an odds ratio of 6.6 for the development of SSI.24Ambiru S. Kato A. Kimura F. et al.Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high volume institute in Japan.J Hosp Infect. 2008; 68: 230-233Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Physiological homeostasis is therefore important in maintaing body defences, and inspired oxygen, controlled blood glucose concentrations and normothermia, among other things, are important.Surgical practiceAppropriate use of antimicrobial prophylaxis, i.e. during induction to ensure adequate tissue levels at the time of the first incision, is associated with reduced SSI rates, particularly with surgical procedures at high risk of infection, such as those involving the gastrointestinal tract. However, it has taken some time before best practice has been incorporated into routine protocols by surgeons and others. Recently, a statement for urological surgery incorporated important principles of appropriate surgical prophylaxis and offered sensible options in terms of the choice of antibiotics for a variety of urological procedures.25Wolf J.S. Bennett C.J. Dmochowski R. Hollenbeck B.K. Pearle M.S. Schaeffer A.J. Best practice policy statement on urologic surgery antimicrobial prophylaxis.J Urol. 2008; 179: 1379-1390Abstract Full Text Full Text PDF PubMed Scopus (596) Google Scholar Indications for prophylaxis are likely to increase with the complexity of surgical procedures performed, and with the increasing longevity of the patient population. For example, antibiotic prophylaxis is not usually recommended for elective clean surgical procedures such as those involving the breast. However, prophylaxis has been recommended for patients undergoing breast cancer surgery if they have had previous chemotherapy, or if the surgery involves reconstruction.26Nicolas P. Yazdanpanah Y. Marie-Pierre C. et al.Prevention of surgical site infection after breast cancer surgery by targeted prophylaxis antibiotic in patients at high risk of surgical site infection.J Surg Oncol. 2007; 96: 124-129Crossref PubMed Scopus (38) Google Scholar Therefore surgeons need to liaise with others, e.g. anaesthetists, microbiologists, infectious disease physicians and others, to ensure that the correct agent is given at the right time and for the appropriate duration.One of the major advances in surgical practice in recent decades has been the development of laparoscopic or minimally invasive surgery. This offers the potential for reducing infection as the incision site is much smaller, but it is unclear whether all other practices and the environment setting associated with open surgery should be replicated. In a survey of 150 hospitals in the UK and Ireland, 3.9–5.6% of minimally invasive surgical procedures associated with urology, e.g. transurethral prosthetic surgery, uretheric stent insertion, etc. took place in a non-ventilated room or in a treatment room with some form of ventilation, but outside a conventionally ventilated theatre.27Smyth E.T.M. Humphreys H. Stacey A. Taylor E.W. Hoffman P. Bannister G. Survey of operating theatre ventilation facilities for minimally invasive surgery in Great Britain and Northern Ireland: current practice and considerations for the future.J Hosp Infect. 2005; 61: 112-122Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarMeta-analysis of laparoscopic compared with open repair of a perforated peptic ulcer suggests that the risk of postoperative SSI is reduced when carried out laparoscopically, and similar findings have been associated with colon surgery.28Lunevicius R. Morkevicius M. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer.Br J Surg. 2005; 92: 1195-1207Crossref PubMed Scopus (108) Google Scholar, 29Romy S. Eisenbring M.-C. Bettschart V. Petignat C. Francioli P. Troillet N. Laparoscope use and surgical site infections in digestive surgery.Ann Surg. 2008; 247: 627-632Crossref PubMed Scopus (100) Google Scholar, 30Poon J.T. Law W.-L. Wong I.W. et al.Impact of laparoscopic colorectal resection on surgical site infection.Ann Surg. 2009; 249: 77-81Crossref PubMed Scopus (106) Google Scholar Most of these procedures currently take place in a full operating theatre, but it may be that some procedures may not require the conventional ventilated theatre with appropriate air changes, air pressures and filters. Surgical factors, e.g. the necessity to convert from a laparascopic to an open procedure if the procedure is complicated, may demand that all laparscopic procedures are carried out in operating theatres, yet the benefits for patients from laparoscopic surgery – irrespective of where it takes place – in terms of reduced morbidity are increasingly clear.Surgical site infection and Staphylococcus aureusStaphylococcus aureus is the commonest cause of SSI and increasingly meticillin-resistant S. aureus (MRSA) accounts for a greater proportion of infections in many hospitals throughout the world. Recommended measures to prevent MRSA will also assist in the reduction of SSI and these include screening, decontamination and glycopeptide prophylaxis.31Rao G.G. Osman M. Johnson L. Ramsey D. Jones S. Fidler H. Prevention of percutaneous endoscopic gastrostomy site infections caused by methicillin-resistant Staphylococcus aureus.J Hosp Infect. 2004; 58: 81-83Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarThe role of pre-emptive mupirocin prophylaxis to the anterior nares to reduce MRSA carriage and its impact on postoperative infection has been studied in detail in recent years. This has to be balanced by the cost of mupirocin, the risk of resistance – particularly with repeated courses – and the impact on postoperative SSI. However, two recent systematic reviews and meta-analyses strongly suggest that prophylactic intranasal mupirocin significantly reduces the rate of postoperative infections including that caused by MRSA and meticillin-susceptible S. aureus (MSSA).32Kallen A.J. Wilson C.T. Larson R.J. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis.Infect Control Hosp Epidemiol. 2005; 26: 916-922Crossref PubMed Scopus (126) Google Scholar, 33van Rijen M. Bonten M. Wenzel R.P. Kluytmans J.A.J.W. Intranasal mupirocin for reduction of Staphylococcus aureus infections in surgical patients with nasal carriage: a systematic review.J Antimicrob Chemother. 2008; 61: 254-261Crossref PubMed Scopus (159) Google Scholar Nonetheless, there is a reluctance to use mupirocin in all patients but to identify those patients most at risk, i.e. those carrying S. aureus or those undergoing certain types of surgery such as orthopaedic and cardiovascular surgery, where the consequences of postoperative infection are great.The rapid detection of S. aureus might potentially assist in achieving this, as only patients carrying S. aureus would receive mupirocin prophylaxis. However, a prospective interventional cohort study on twelve surgical ward patients using PCR to detect MRSA did not lead to a reduction overall in HCAI;34Harbath S. Fankhauser C. Schrenzel J. et al.Universal screening for methicllin-resistant Staphylococcal aureus at hospital admission and nosocomial infection in surgical patients.J Am Med Assoc. 2008; 299: 1149-1157Crossref Scopus (442) Google Scholar the failure of this study to demonstrate a benefit may be partly related to the local setting, where MRSA was not endemic. Alternatively, there may have been a failure of one intervention, i.e. rapid MRSA detection, to impact on what is a multifactorial process.Converting theory to practiceDespite the scientific literature, and t" @default.
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• W2080161356 title "Preventing surgical site infection. Where now?" @default.
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