Nasal Staphylococcus aureus Carriage Increases Risk of Surgical Site and Bloodstream Infections

แนวคิดหลัก

Nasal carriage of Staphylococcus aureus is associated with an increased risk of surgical site and bloodstream infections following surgical procedures.

บทคัดย่อ

This article reports the findings of a large, prospective, multicenter clinical study conducted across 33 hospitals in 10 European countries. The study included 5,004 patients and examined the relationship between Staphylococcus aureus (SA) carriage and the risk of surgical site or bloodstream infections.
The key insights from the study are:

67.3% of the patients were found to be SA carriers.
Patients with SA carriage at any site (adjusted hazard ratio [aHR] of 4.6) and nasal SA carriage (aHR of 4.2) had a significantly higher risk of developing surgical site or bloodstream infections compared to non-carriers.
Extranasal SA carriage was not associated with an increased infection risk.
A one-unit increase in nasal bacterial load was associated with a 23% increase in the risk of infection.
The World Health Organization (WHO) strongly recommends nasal decolonization using mupirocin ointment with or without chlorhexidine gluconate bodywash for cardiothoracic and orthopedic surgeries, and has a conditional recommendation for other types of surgery. However, this practice is not widely adopted.
The researchers are still puzzled by the specific link between nasal SA carriage and surgical infections, and would like to further investigate the underlying mechanism.

สถิติ

67.3% of the 5,004 patients were found to be Staphylococcus aureus carriers.
Patients with Staphylococcus aureus carriage at any site had a 4.6-fold increased risk of surgical site or bloodstream infections (95% CI, 2.1-10.0).
Patients with nasal Staphylococcus aureus carriage had a 4.2-fold increased risk of surgical site or bloodstream infections (95% CI, 2.0-8.6).
A one-unit increase in nasal bacterial load was associated with a 23% increase in the risk of infection (aHR, 1.23; 95% CI, 1.05-1.43).

คำพูด

"This was a pan-European study with many hospitals, many different clinical settings, and as far as I'm aware, it hasn't been done before. [The new study] covers a lot of European countries and a lot of surgical specialties."
"If I would come into surgery being a carrier and not be decolonized, I would really be quite angry because it puts you at risk, which is preventable. I think that's something we owe to our patients."
"It really made me wonder if it would have added even more credibility to the study if there had been a sample taken after surgical prep was done to demonstrate that there is actually no S aureus present on the skin at the time that the wound was made."

ข้อมูลเชิงลึกที่สำคัญจาก

Nasal S aureus Carriage Linked to Surgical Infections

by Jim Kling ที่ www.medscape.com 09-25-2024

https://www.medscape.com/viewarticle/s-aureus-nose-linked-blood-and-surgical-site-infections-2024a1000he1

สอบถามเพิ่มเติม

What are the potential mechanisms by which nasal Staphylococcus aureus carriage leads to an increased risk of surgical site and bloodstream infections?

Nasal Staphylococcus aureus (SA) carriage is a significant risk factor for surgical site and bloodstream infections due to several potential mechanisms. Firstly, the nasal cavity serves as a reservoir for SA, which can be transferred to the surgical site during procedures. This transfer may occur through direct contact with surgical instruments, the hands of healthcare providers, or through airborne particles. Secondly, the presence of SA in the nasal passages can lead to colonization of the skin and mucosal surfaces, increasing the likelihood of contamination during surgery.
Moreover, the study indicates that a higher bacterial load in the nasal cavity correlates with an increased risk of infection, suggesting that the quantity of SA may play a critical role in the pathogenesis of infections. Additionally, the immune response of the patient may be compromised due to surgical stress, allowing for the proliferation of SA and subsequent infection. The "trojan horse" hypothesis further posits that endemic carriage of SA within the body, rather than external contamination, may be responsible for many surgical site infections, highlighting the need for effective decolonization strategies.

What are the barriers to the widespread adoption of nasal decolonization strategies, despite the strong recommendations from the World Health Organization?

Despite the strong recommendations from the World Health Organization (WHO) for nasal decolonization, several barriers hinder its widespread adoption. One significant barrier is the lack of awareness and education among healthcare providers regarding the benefits and effectiveness of decolonization strategies. Many facilities may not have established protocols for routine screening and decolonization, leading to inconsistent practices.
Additionally, concerns about the potential for antibiotic resistance associated with decolonization efforts may deter some practitioners from implementing these strategies. Although short-term prophylaxis is generally considered safe, the fear of contributing to resistance can overshadow the immediate benefits of reducing infection risk.
Resource limitations, including the availability of mupirocin and chlorhexidine gluconate, as well as the costs associated with implementing decolonization protocols, can also pose challenges, particularly in resource-constrained healthcare settings. Finally, institutional inertia and resistance to change in established surgical practices can impede the integration of new evidence-based interventions, despite their proven efficacy.

How can the findings of this study be leveraged to improve patient outcomes and reduce the burden of surgical-site infections in healthcare settings?

The findings of this study can be leveraged to improve patient outcomes and reduce the burden of surgical-site infections (SSIs) through several strategic approaches. Firstly, healthcare institutions should prioritize the implementation of routine nasal screening for SA carriage in surgical patients, particularly those undergoing high-risk procedures such as cardiothoracic and orthopedic surgeries.
Following screening, effective decolonization protocols, including the use of mupirocin and chlorhexidine gluconate, should be standardized and integrated into preoperative care pathways. This proactive approach can significantly reduce the incidence of SSIs by addressing the source of potential contamination before surgery.
Furthermore, education and training programs for healthcare providers about the importance of nasal decolonization and the mechanisms by which nasal SA contributes to infections can foster a culture of safety and compliance. Engaging patients in the process by informing them about the benefits of decolonization can also enhance adherence to preoperative protocols.
Finally, ongoing research should be encouraged to explore the mechanisms of SA transmission during surgical procedures, as well as the long-term effects of decolonization on antibiotic resistance. By continuously evaluating and refining decolonization strategies based on emerging evidence, healthcare settings can enhance patient safety and reduce the overall burden of SSIs.