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THE NOSE HAS IT Staphylococcus aureus is commonly carried in the nasal passages.About one-third of your patients are carriers of Staphylococcus aureus. They likely don't know it. And neither do you. But their nose knows. That's right. The nose has been long known to be a primary reservoir of S. aureus. Patients who carry staph bacteria in their nares are at increased risk for surgical site infections that are caused by this bacteria. Thanks to the recent development of several low-cost nasal decolonization options, you can screen, swab and sanitize patients' nares before surgery in order reduce the risk of post-op infection. Is this ounce of SSI prevention worth a pound of cure?
- Screen select patients. Should you screen every patient for S. aureus? That might not be necessary. "You have to consider the types of surgeries you're performing, the patients you're hosting and your facility's history of infection," says Phenelle Segal, RN, CIC, president of Infection Control Consulting Services in Delray Beach, Fla. Patients who are likely carriers come from long-term care facilities, have history of Methicillin-resistant Staphylococcus aureus (MRSA) infection or have been recently hospitalized, says Ms. Segal.
The evidence doesn't support screening for patients undergoing eye surgery, for example, but you can cost-justify testing patients if you host orthopedic and spine cases, which typically involve high-risk patients.
The direct financial costs of treating surgical site infections, as well as the associated risks of morbidity and mortality, have increased the awareness and use of pre-op screening for multidrug-resistant organisms, says Ms. Segal. "We're seeing a lot more screening done in the outpatient setting as surgeons and caregivers are beginning to understand the financial burden surgical site infections place on facilities and patients."
Ms. Segal points out that screening isn't a significant expense and companies have introduced screening kits with rapid turnaround times. "If a facility feels that the risk assessment of a patient indicates an increased risk of surgical site infection, and the surgery type justifies screening, they should test the patient, because they can decolonize positive patients before surgery," she says.
Immediate-result screenings aren't yet available. Swabbing must occur at least 5 days before surgery, because that's how long treatment with the nasal decolonizing agent mupirocin takes to complete, says Ms. Segal.
- Screen everyone. Antonia Chen, MD, MBA, a joint replacement specialist at the Rothman Institute in Philadelphia, screens every patient scheduled to undergo primary or revision hip and knee replacements for S. aureus with the hope of reducing the risk of post-op infection.
PROVEN RESULTS
The Value of Preventing Post-op Infections
HIGH RISK Implants in total joint patients habor dangerous bacteria that can cause surgical site infections.Orthopedic surgeons at NYU Langone Medical Center say primary knee replacements cost about $15,000, while performing revision surgery to remove and replace an infected implant can run as much as $70,000. They used the significant cost of treating surgical site infections and the financial benefit of achieving even a small reduction in the rate of post-op infections to drive implementation of a universal screening program for Staphylococcus aureus at the Manhattan hospital.
James Slover, MD, an orthopedic surgeon at NYU Langone, helps lead the program, which involves screening all total joint patients with nasal swabs before surgery and prophylaxis treatment with the antibiotic mupirocin. Patients are also asked to perform chlorhexidine showers the night before surgery or use chlorhexidine wipes the night before and day of surgery.
The results of the screening are available the day of surgery. Patients who are MRSA-negative receive standard perioperative antibiotic prophylaxis with either cefazolin or clindamycin at least 30 ?minutes before incision time and for 24 hours post-operatively. Patients who are MRSA-positive receive vancomycin intravenously at least 30 minutes before incisions are made and every 12 hours after surgery for 24 hours.
Results from 1,300 patients who underwent the hospital's screening and decolonization protocol show the program reduced the post-op infection rate from 1.5% to 1%. As Joseph A. Bosco, MD, an orthopedic surgeon at NYU Langone, points out, that reduction would prevent 5 infections for every 1,000 patients treated.
At NYU Langone, the approximate per-patient charge for nasal screening and prophylaxis with mupirocin is $105 — a relatively low figure, especially when you consider the high cost of treating just one surgical site infection, says Dr. Slover. He says any significant reduction in infection rates will be highly cost-effective. "If we can establish that," says Dr. Slover, "then screening and decolonization is likely to become a widely used pre-operative infection control intervention."
Dr. Chen says joint replacement patients undergoing revision surgery, who are a high-risk population, comprise 30 to 40% of her joint replacement cases. Patients undergoing primary replacements are less likely than revision patients to carry S. aureus, but are still at heightened risk. Dr. Chan says 20 to 30% of her patients have S. aureus and 1 to 5% test positive for MRSA.
S. aureus accounts for the majority of SSIs in orthopedic patients, says Dr. Chen, who notes that SSIs associated with S. aureus following joint replacement procedures are difficult to treat, because the bacteria forms a biofilm on implants that's often resistant to antibiotic treatment.The cost of screening is facility-dependent, but a nasal swab and culture test typically runs about $20 and intranasal mupirocin is about $90. "We're not talking about thousands of dollars," says Dr. Chen. "But you also have to consider the indirect staffing costs associated with swabbing patients, following up on lab results and calling in antibiotic prescriptions to treat patients who test positive."
Dr. Chen cites research that says a 35% reduction in the revision rate for total hip and knee replacements and a 10% reduction in the revision rate for spine surgery are needed to make screening and decolonization cost-effective. But in her mind, the cost of preventing just one surgical site infection is worth the screening and treatment process.
Some experts advocate for treating all patients as if they have S. aureus, even if they screen negative, says Dr. Chen. However, she doesn't recommend treating every patient with mupirocin for a possible infection, because it could lead to antibiotic resistance.
SCREEN SHOT A nasal swab and culture test typically runs about $20.- Sanitize everyone. Some say it costs less to reduce nasal colonization in most patients than it does to screen them. New to the market are a few nasal antiseptic swabs that let you decolonize the nose without the risk and complexity of antibiotics, for about $10 per patient. Think hand sanitizer for your nose. Patients can apply the swabs the night or the hour before surgery. "Patients are already being asked to wash pre-operatively with CHG," says Ms. Segal. "This could be added to that regimen."
One nasal sanitizer resembles a tube of ChapStick lip balm. It's made of ethyl alcohol and natural emollients. The night before surgery, patients snap a prefilled ampule and then swab a tip around their nostril rims 6 times in each direction.
Another type employs a povidone-iodine solution and is as simple as using a Q-tip. About 1 hour before surgery, patients insert a premoistened swab into each nostril and rotate for 30 seconds, covering all surfaces. They repeat the application in both nostrils 4 times.
"It's much less expensive and less time-consuming than screening and decolonizing, and is more pleasant for patients," says Ms. Segal. Plus, nasal sanitizing eliminates the need to screen patients for signs of S. aureus and delay surgery until treatment, if needed, is complete. OSM
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