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Preventive Measures For Large Joint Surgeries


An infection prevention bundle for large joint surgery. (also Sternotomy, spine surgery and other large medical devices like defibrillators).

Medical devices and large joints cost a lot to place and infection of these can be life threatening and catastrophic. Prevention of infections may become complicated but is less costly-not to mention the misery prevented.

This is a work in progress but together with infection prevention, pre-op education the following proposed bundle of interventions may help with the prevention of medical device infections in the vulnerable.

So what are the rates of Methicillin resistant Staphylococcus aureus (MRSA) and Methicillin Sensitive Staphylococcus aureus (MSSA )infections of devices at your institution? and how they compare to Nationally reported rates? How many MSSA vs MRSA?

Numbers similar to ones reported elsewhere?

(Per Rao et al / University of Pittsburg)

636 screened (nasal)

26% positive for S. aureus (164/636)

23% MSSA (147/636)

3% MRSA (17/636)

NE Baptist published numbers from anonymous screening in surgery

February 2006

133 anonymous nares cultures after patient anesthetized

Results:

38 MSSA (29%)

*5 MRSA (4%)

All previously undiagnosed

Reasons for testing for Nasal carriage of Staphylococcus.

  1. Nasal carriage only independent risk factor for S. aureus SSI in orthopedic implant surgery

  2. Surgical Site infection (SSI) rate 2-9x higher in carriers

  3. In S. aureus SSI, S.aureus isolates from wound match nares 85% of time

THE PERIOPERATIVE ANTIBIOTICS AND CARE BUNDLE FOR PATIENTS SCREENED FOR MSSA AND MRSA

examples..

  1. Large joints (Hips and knees stressed-may be expanded to shoulder)

  2. Spinal surgery including stimulators/pain management devices

  3. CT surgery: Sternotomy and devices like defibrillators and pacemakers

  4. Other Medically implanted devices: Pain stimulators

Note In emergency situations with above surgeries protocol to be followed as if these were screened positive for MRSA-accelerated protocol of CHG bathing or equivalent and nares mupirocin to be begun prior to surgery and completed afterwards, nares iodine peri-operatively

The bundle or peri-op antibiotics may be used for other high risk surgery as surgical team and anaesthesia department discretion-plastics, breast augmentation etc.

THE MRSA/MSSA Bundle

CARE BUNDLE

*Note: 24/7 Beeper/Cellphone coverage by ID physician and availability of ASP Pharmacist on weekdays.

*Note to pharmacists: Orthopedic surgeons and anesthesiologists have the option of 1x dosing other abx like Vancomycin/Daptomycin/Linezolid in appropriate doses based on clinical judgment

  • TKR and THR

  • Other large joints

  • Sternotomy

  • Pacer/Defibrillator/Spinal Stimulators

  • Spinal surgery

  • Other (large implants)

NARES SCREEN

IF NARES (-) NEGATIVE

Standard Precautions Recommended

That is ..consider

  1. CHG bathing

  2. Nares iodine

  3. Standard PeriOp Abx-Cefazolin 2g-3gx1*

POSITIVE NARES SCREEN FOR MSSA

THE MSSA BUNDLE

  1. Nares povidone iodine swab

  2. MUPIROCIN

  3. CHG Bath 5DAYS with supply Bundle

  4. TEACHING by handouts and 2 visits

  5. preop: Cefazolin 2g-3gx 1*

IF NARES (+) POSITIVE: MRSA

OR Emergent procedures- if screen not done-Count as MRSA positive

  1. Nares povidone iodine swab

  2. MUPIROCIN

  3. CHG Bath 5DAYS with supply Bundle

  4. TEACHING by handouts and 2 visits

  5. preop-BOTH Vancomycin 15mg/kg + Cefazolin 2-3gx1*

Some subtleties:

  1. If PCN anaphylaxis Vancomycin alone, If PCN mild allergy >10yrs ago/consider IV Cefazolin

  2. In high-risk cases with PCN anaphylaxis based on clinical judgment consider ID/ASP referral and consider linezolid or Daptomycin

  3. Note: some patients refuse iodine

  4. Nares iodine does not work if wounds present and these patients may need mupirocin treatment to wounds.

  5. Mupirocin compliance need not be 100% if iodine being used-it just needs to be good in 25-50 with MRSA.

  6. Mupirocin may be started day of surgery and completed after surgery

Advantage of a bundled protocol:

  1. Evidence based. (some!)

  2. Microbiological record of infecting MSSA, MRSA flora if future infections

  3. Opportunity for planning drug infusions

  4. Lower numbers given vancomycin (Given only in those screened positive)

  5. Opportunity for patient teaching

  6. Infection prevention

Adaptable for other surgeries

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