Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery

Importance

Previous studies suggested that a bundled intervention was associated with lower rates ofStaphylococcus aureussurgical site infections (SSIs) among patients having cardiac or orthopedic operations.

Objective

To evaluate whether the implementation of an evidence-based bundle is associated with a lower risk ofS aureusSSIs in patients undergoing cardiac operations or hip or knee arthroplasties.

Design, Setting, and Participants

Twenty hospitals in 9 US states participated in this pragmatic study; rates of SSIs were collected for a median of 39 months (range, 39-43) during the preintervention period (March 1, 2009, to intervention) and a median of 21 months (range, 14-22) during the intervention period (from intervention start through March 31, 2014).

Interventions

Patients whose preoperative nares screens were positive for methicillin-resistantS aureus(MRSA) or methicillin-susceptibleS aureus(MSSA) were asked to apply mupirocin intranasally twice daily for up to 5 days and to bathe daily with chlorhexidine-gluconate (CHG) for up to 5 days before their operations. MRSA carriers received vancomycin and cefazolin or cefuroxime for perioperative prophylaxis; all others received cefazolin or cefuroxime. Patients who were MRSA-negative and MSSA-negative bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown.

Main Outcomes and Measures

The primary outcome was complex (deep incisional or organ space)S aureusSSIs. Monthly SSI counts were analyzed using Poisson regression analysis.

Results

After a 3-month phase-in period, bundle adherence was 83% (39% full adherence; 44% partial adherence). Overall, 101 complexS aureusSSIs occurred after 28 218 operations during the preintervention period and 29 occurred after 14 316 operations during the intervention period (mean rate per 10 000 operations, 36 for preintervention period vs 21 for intervention period, difference, −15 [95% CI, −35 to −2]; rate ratio [RR], 0.58 [95% CI, 0.37 to 0.92]). The rates of complexS aureusSSIs decreased for hip or knee arthroplasties (difference per 10 000 operations, −17 [95% CI, −39 to 0]; RR, 0.48 [95% CI, 0.29 to 0.80]) and for cardiac operations (difference per 10 000 operations, −6 [95% CI, −48 to 8]; RR, 0.86 [95% CI, 0.47 to 1.57]).

Conclusions and Relevance

In this multicenter study, a bundle comprisingS aureusscreening, decolonization, and targeted prophylaxis was associated with a modest, statistically significant decrease in complexS aureusSSIs.