Multiresistant pathogens in surgery

Nosocomial infections caused by multidrug resistant organism (MDRO) are an increasingly common healthcare-associated problem. In surgery methicillin-resistant Staphylococcus aureus (MRSA) is still the most important of these bacteria, and the management of MRSA infections and the prevention of their nosocomial transmission are a major challenge. Hence, a comprehensive strategy for the prevention of nosocomial MRSA infections is imperative including optimization of antibiotic use in hospital, antibiotic stewardship as well as admission surveillance cultures, and improved compliance of hand hygiene.     

Increasing Multidrug Antibiotic Resistance in MRSA Infections of the Hand: A 10-Year Analysis of Risk Factors

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen isolated from hand abscesses. The purpose of this study was to understand trends and changes in longitudinal antibiotic resistance profiles and risk factors for these infections to better guide empiric treatment of hand infections. Methods: We performed a retrospective review of culture-positive hand infections over a 10-year period at an urban academic institution from 2005 to 2014. A subset of MRSA hand infections from 2013 to 2014 was then subanalyzed for risk factors for antibiotic resistance for antibiotics with increasing antibiotic resistance during this period. Results: MRSA grew in 46% of hand infections, with a decreasing incidence over the 10-year study period. However, in the same time period clindamycin and levofloxacin resistance increased from 7% to 31% and 12% to 56%, respectively. Risk factors for clindamycin resistance included nosocomial infections and a history of intravenous drug use and hepatitis C. Risk factors for levofloxacin resistance included a history of diabetes and a fever upon initial presentation. Conclusions: The incidence of multidrug resistance remains high, with growing resistance to clindamycin and levofloxacin. There remains a trend for increased clindamycin resistance for patients with history of intravenous drug use and nosocomial infections. Our findings indicate that clindamycin and levofloxacin should be avoided for empiric treatment for hand infections in patients with these risk factors.     

Community-Acquired Methicillin-Resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> in the Suburban Hand Surgery Patient Population

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause for patients to present to a physician’s office or emergency department. We observed increasing numbers of community-acquired MRSA infections in patients admitted to the hand surgery service at our suburban academic center. It is an important issue as unsuspected community-acquired MRSA hand infections can be admitted to the hospital, inadequately treated, and allowed for nosocomial spread. This study was performed to examine the trend in the incidence of community-acquired MRSA infections in patients admitted to the hand surgery service in order to sensitize practitioners to have a high index of suspicion for this entity and promote early recognition and treatment of this organism. A multihospital retrospective chart review was undertaken to compare the total number of community-acquired MRSA infections in our hospital as well as the number in patients admitted to the hand surgery service with community-acquired MRSA from 2000 through 2008. Statistical analysis was provided by linear regression. Two community-acquired hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six in 2005, 14 in 2006, 13 in 2007, and ten in 2008. This increase was statistically significant (p = 0.038). This retrospective review documents a rapidly rising number of community-acquired MRSA hand infections in the suburban environment. The hand surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.     

Enteral feeding tubes are a reservoir for nosocomial antibiotic-resistant pathogens

Background: Patients and their surroundings are known reservoirs for nosocomial pathogens. Enteral feeding tubes and formula are not thought of as reservoirs for nosocomial organisms. Methods: A prospective observation study was conducted comparing methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) cultured from nosocomial infections and MRSA/VRE cultured from enteral feeding tubes used in the same neonatal intensive care unit during the same time period but in different babies. DNA fingerprinting then was used to compare MRSA and VRE cultured from feeding tubes with MRSA/VRE isolates cultured from clinical infections. Results: There were 23 S aureus isolates; 12 of 23 were methicillin resistant (MRSA). There were 4 MRSA infections in patients without feeding tubes. DNA fingerprinting showed that the MRSA species causing each of the clinical infections also was found in the feeding tubes of other babies. There were no vancomycin-resistant Enterococcus infections during the study period. Conclusion: Feeding tubes are a reservoir for antibioticresistant pathogens that can be transmitted to other infants. J Pediatr Surg 37:1011-1012.     

Kolonisation und Infektion durch methicillinresistente Staphylococcus-aureus-Stämme

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) strains have a major impact on antimicrobial therapy as they cannot be treated with the most effective compounds. Numerous studies have shown that MRSA infections are associated with increased mortality as well as a longer stay in the hospital. Various strategies for preventing MRSA have been shown to be successful, but only a few countries have rigorously applied these strategies. At present, the situation is becoming worse due to the emergence of so-called “community-associated MRS”. This review highlights the multifarious implications of colonisation and infections due to this pathogen.     

Nasal MRSA screening for surgical patients: predictive value for postoperative infections caused by MRSA

Purpose

Postoperative methicillin-resistant Staphylococcus aureus (MRSA) infections are occasionally fatal. We hypothesized that nasal MRSA screening might predict the risk of postoperative MRSA infections. The aim of the current study was to elucidate the relationship between the positivity of nasal MRSA screening and postoperative MRSA infections.

Methods

Six hundred and fourteen surgical patients who were admitted to the intensive care unit and underwent nasal MRSA screening between April 2006 and March 2011 were divided into MRSA-positive and -negative groups. The incidence of postoperative MRSA infections in the MRSA-positive and MRSA-negative groups were compared, and various risk factors for MRSA infections were evaluated.

Results

The incidence of postoperative MRSA infections, such as pneumonia and enteritis, in the MRSA-positive group was significantly higher than that in the MRSA-negative group (41.9 vs. 3.1 %). The significant independent risk factors for postoperative MRSA infections were a positive MRSA screening, an operation lasting more than 300 min and an emergency operation. A positive MRSA screening was the most statistically significant risk factor for postoperative MRSA pneumonia and enteritis, but was not a risk factor for MRSA surgical site infections.

Conclusion

Nasal MRSA screening can help to identify patients who have an increased risk of developing postoperative MRSA infections, and would enable physicians to take a prompt action if these complications occur.     

Meta-Analysis of Methicillin-Resistant Staphylococcus aureus Colonization and Risk of Infection in Dialysis Patients

Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (6–20 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection.Invasive methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with mortality that is as high as 30%.¹ ESRD patients have a 100-fold higher risk of MRSA infection compared with the general population.² Among 80,461 invasive MRSA infections in 2011, 15,169 (18.9%) were among dialysis patients.³ Although a significant proportion of S. aureus infections are of endogenous origin,⁴ the relative risk of MRSA infections in colonized patients in this population is largely unknown. Our aim is to comprehensively assess the available data and give a global picture of MRSA colonization among dialysis patients. In this systematic review and meta-analysis, we estimate the prevalence of MRSA colonization among ESRD patients on dialysis treatment and study the significance of MRSA colonization in this population.     

Geographic information system localization of community-acquired MRSA soft tissue abscesses

Background

Soft tissue infections with methicillin-resistant Staphylococcus aureus (MRSA) pose an ever-increasing risk to children in the community. Although historically these infections were limited to children with prolonged hospitalization, the authors have seen an increase in community-acquired infections in children without identifiable risk factors. The goal of this study is to determine the incidence of truly community-acquired MRSA soft tissue infections in our community and geographically map regions of increased risk.

Methods

After obtaining the institutional review board's approval, a retrospective chart review was conducted on 195 patients records who underwent an incision and drainage of soft tissue infections from January 1, 2000, to December 31, 2003. Thirteen patients were excluded from the study because no cultures were taken at the time of incision and drainage.

Results

The most common organism isolated from wound culture was S aureus, 40% (73/182), of which 45% (33/73) were MRSA. Eighty-one percent (27/33) of MRSA infections were in Springfield, 1 of 18 towns represented in the patient population. Geographic information system analysis identified a significant MRSA cluster 1.96 km in diameter within the city of Springfield.

Conclusions

Geography proved to be a significant risk factor for presenting with MRSA infection. Geographic maps of antibiotic resistance can be used to guide physician antibiotic selection before culture results are available. This has significant implications for the health care provider in proper antibiotic selection within the community.     

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections

Background

Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs) increase morbidity and mortality. We examined the impact of the MRSA bundle on SSIs.

Methods

Data regarding the implementation of the MRSA bundle from 2007 to 2008 were obtained, including admission and discharge MRSA screenings, overall MRSA infections, and cardiac and orthopedic SSIs. Chi-square was used for all comparisons.

Results

A significant decrease in MRSA transmission from a 5.8 to 3.0 per 1,000 bed-days (P < .05) was found after implementation of the MRSA bundle. Overall MRSA nosocomial infections decreased from 2.0 to 1.0 per 1,000 bed-days (P = .016). There was a statistically significant decrease in overall SSIs (P < .05), with a 65% decrease in orthopaedic MRSA SSIs and 1% decrease in cardiac MRSA SSIs.

Conclusion

Our data demonstrate that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs.     

Methicillin-resistant Staphylococcus aureus hand infections in a suburban community hospital

Of hand infections treated in a suburban community hospital, 65% were found to have cultures positive for methicillin-resistant Staphylococcus aureus (MRSA). This incidence of MRSA infection is comparable to MRSA infection rates found in county hospitals and trauma center hand infection populations. MRSA should be recognized as a common primary pathogen in hand infections.     

Prevalence of MRSA colonization in an adult urban Indian population undergoing orthopaedic surgery

IntroductionOrthopaedic surgery is technically demanding, implant dependant and expensive. Infection translates into a prolonged morbidity and long-term use of antibiotics. The most common organism involved in osteo-articular infections is Staphylococcus aureus, and colonizes the anterior nares of 25–30% of the population. Carriers are at higher risk for staphylococcal infections after invasive medical or surgical procedures. Prevalence of methicillin resistant Staphylococcus aureus (MRSA) has not been assessed in patients admitted for orthopaedic surgery in the Indian setting.AimTo assess the preoperative prevalence of MRSA colonization in adult patients undergoing orthopaedic surgery in urban India.Materials and methodsThis is a retrospective analysis of patients from 2009 to 2013. A total of 1550 patients admitted for orthopaedic surgery were preoperatively screened with nasal and axillary swabs for MRSA. Swab-positive patients were treated with intranasal mupirocin ointment for 3 days followed by a repeat swab. A record was made of hospitalization in the year prior to surgery and the occurrence of surgical site infection (SSI).ResultsA total of 690 males and 860 females had been screened for MRSA using an inexpensive kit costing 500 Indian rupees. For MRSA, 7/1550 (0.45%) nasal swabs were positive. No patient since 2009 has had a SSI with MRSA.ConclusionMRSA screening prior to orthopaedic surgery is a valuable and cost effective preoperative investigation even though the incidence is low. Mupirocin is effective in clearing MRSA from the nares and maybe used for 3 days to obtain elimination of the bacteria.     

Methicillinresistenter Staphylococcus aureus in der Mund-, Kiefer- und Gesichtschirurgie

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) as well as other multi-resistant bacteria represent a serious issue in nosocomial infections. Nosocomial infections can lead to an extended hospital stay in older and immunosuppressed patients and cause higher costs combined with a higher morbidity and mortality of patients. Therefore, MRSA screening before admission to hospital as well as hygienic standards on the ward become particularly important. Community-acquired MRSA can cause infections even in immunocompetent patients and should be identified through an antibiogramm and sequence typing of hospital-acquired MRSA. How often patients in the outpatient and the oral and maxillofacial surgery wards as well as in the dental office are colonized with MRSA and how often infections through MRSA occur is poorly documented in the literature. The aim of the article is to summarize the literature and to survey possible risk factors for MRSA colonization and infection in dental oral and maxillofacial surgery patients.     

Characteristics of Musculoskeletal Involvement in Pediatric Patients with Disseminated Sepsis in a Tertiary Care Center

BackgroundPediatric bone and joint infections account for one of the major causes of childhood morbidity. Disseminated sepsis being a systemic disorder with multisystem involvement, overshadows the timely recognition of bone and joint infections. Hence, we did this cross sectional study to evaluate the prevalence of septic arthritis and osteomyelitis in disseminated sepsis in children, the organisms implicated, and their antibiotic sensitivities.MethodsWe prospectively collected data from 1st July 2016 to 31st September 2017 of children aged less than 12 years with disseminated sepsis, i.e., patients with fever and two or more sites of focal infection of anatomically non-contiguous tissues.ResultsFifty-four patients of disseminated disease were included, of which 25 patients (46.3%) had osteoarticular infections. Septic arthritis was seen in 17 patients, and osteomyelitis was seen in 12 patients. The most common joint was hip (41.6%), and the most common bone involved was femur (53.8%). Blood culture showed MRSA in 28% and MSSA in 20%. Joint and bone aspirates showed S. aureus in 56% with 28% of MRSA and MSSA each. All Staphylococcus aureus organisms were found sensitive to vancomycin and teicoplanin. The mean values of CRP, duration of stay and duration of intravenous antibiotic was higher in MRSA infected patients compared to MSSA patients.ConclusionsStaphylococcus aureus is the most prevalent organism in musculoskeletal infection in disseminated sepsis children, with vancomycin sensitivity of 100% and methicillin sensitivity of 46.2% only. Cases of osteoarticular involvement with MRSA were higher compared to MSSA among the cases of disseminated disease. The prevalence of osteoarticular involvement is high in disseminated sepsis in children and increased clinical suspicion for such must be maintained.     

Impact of Preoperative MRSA Screening and Decolonization on Hospital-acquired MRSA Burden

Background

Hospital-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are a source of morbidity and mortality. S. aureus is the most common pathogen in prosthetic joint infections and the incidence of MRSA is increasing.

Questions/Purposes

The purposes of this study were (1) to determine the MRSA prevalence density rate at a specialty orthopaedic hospital before and after implementation of a screening and decolonization protocol, (2) to compare our prevalence density with that of an affiliated university hospital to control for changes in MRSA prevalence density that might have been independent of the decolonization protocol, and (3) to measure the admission prevalence density rate of MRSA in an elective orthopaedic surgery population and the compliance rate of 26 patients with the protocol.

Methods

In October 2008, we implemented a MRSA screening and decolonization protocol for patients undergoing elective orthopaedic surgery. Nasal swabs were used for screening and mupirocin nasal ointment and chlorhexidine skin antisepsis where prescribed for decolonization to all patients. At the surgical visit, compliance was measured and the patients who were MRSA positive received vancomycin for antibiotic prophylaxis. Institution wide surveillance for multidrug-resistant organisms, including MRSA provided a comparison of the change in MRSA burden at the orthopaedic hospital versus the university hospital.

Results

Before implementation of the preoperative staphylococcal decolonization protocol there were 79 MRSA-positive cultures in 64,327 patient-days for a prevalence density rate of 1.23 per 1000 patient-days. After protocol implementation, 53 MRSA-positive cultures were identified in 63,860 patient-days for a rate of 0.83 per 1000 patient-days. Before the protocol, the MRSA prevalence density at the specialty hospital was similar to that of the university hospital; after implementation of the protocol, the prevalence density at the specialty hospital was 33% lower than that of the university hospital. The MRSA admission prevalence was 3.02%. The compliance rate was greater than 95%.

Conclusions

Implementation of a staphylococcal decolonization protocol at a single specialty orthopaedic hospital decreased the prevalence density of MRSA.     

Monomicrobial necrotizing fasciitis caused by coagulase-negative Staphylococci and methicillin-resistant Staphylococcus aureus

Background

Coagulase-negative staphylococci (CoNS) have been reported to cause necrotizing fasciitis; however, there are some difficulties in differentiating the roles of CoNS infections as contaminants or pathogenic isolates. Methicillin-resistant S. aureus (MRSA) has emerged as the most common isolate to cause necrotizing fasciitis in the past decade. This study was to compare the clinical presentation and surgical outcome of CoNS and MRSA monomicrobial necrotizing fasciitis, and to assess the prevalence of CoNS and MRSA infection in diabetic patients.

Methods

Necrotizing fasciitis caused by CoNS in 11 patients and that caused by MRSA in 27 patients was retrospectively reviewed. Demographic data, underlying diseases, laboratory results, and clinical outcome were analyzed for each patient in two groups.

Results

All patients underwent fasciotomy and received broad-spectrum antibiotic therapy. The mortality of MRSA group and CoNS group was 18.5 and 9%, respectively. Mortality, patient characteristics, clinical presentations, and laboratory data did not differ significantly between the two groups. Eight of CoNS patients (73%) and fourteen of MRSA patients (52%) had significant association with diabetes mellitus.

Conclusions

Necrotizing fasciitis caused by CoNS is a surgical emergency and should be considered to be serious as that caused by MRSA. Diabetic patients with a history of abrasion injury or chronic ulcer should be cautioned about the risk of developing CoNS and MRSA necrotizing fasciitis.     

Community-associated methicillin-resistant Staphylococcus aureus hand infections in an urban setting

PURPOSE: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection appears to be increasing. The purpose of this study was to determine prospectively the incidence of MRSA in community-associated hand infections in an urban hospital. METHODS: Sixty-one patients presented to our institution over a 9-month period with community-acquired hand infections that were evaluated and treated by the hand service. The specimens obtained during the initial evaluation and treatment were cultured and subjected to antibiotic susceptibility testing. Four nosocomial infections and 5 fight bites were excluded. RESULTS: Of the remaining 52 patients, 38 (73.1%) were MRSA positive. CONCLUSIONS: The rate of community-associated MRSA hand infections in an urban setting is higher than previously suspected. This should be taken into account when managing seemingly routine hand infections given that the treatment options are different for MRSA infections. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Carriage of methicillin-resistant Staphylococcus aureus is associated with an increased risk of infection after liver transplantation

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of sepsis in patients with cirrhosis and after liver transplantation. The association between nasal carriage of MRSA and sepsis in these patients is unclear. The goal of this study was to investigate the relationship between MRSA carriage before liver transplantation and subsequent sepsis after transplantation. This was a retrospective study of 374 consecutive adults who underwent orthotopic liver transplantation between 1998 and 2001 and for whom full data were available. Of these, 157 had been screened for MRSA as part of a study assessing the prevalence of MRSA infection. All MRSA carriers were treated with nasal mupirocin and chlorhexidine baths. The records of MRSA carriers and noncarriers were analyzed for Child and Model for End-Stage Liver Disease (MELD) score, posttransplantation MRSA, and other infections and mortality. Of the 157 patients who had an MRSA screen, 35 patients were MRSA nasal carriers. These carriers had significantly greater MELD score (mean, 16.2 compared with 13.1; P = .02) and Child scores (mean, 10 versus 9; P = .001) than noncarriers. The incidence of posttransplantation MRSA infection was significantly higher in MRSA carriers (31% versus 9%; P = .002). The incidence of other posttransplantation infection was not significantly different in the two groups. There was no significant difference in survival between the two groups (1-year patient survival, 74% and 82%, respectively). Patients carrying MRSA are predisposed to an increased risk of sepsis after liver transplantation with a trend to increased mortality. Screening for MRSA should be considered in high-risk patients being assessed for liver transplantation. (Liver Transpl 2003;9:754-759.)     

Prävention von MRSA-Übertragungen: Standardhygiene statt Isolierung

Background

This study was carried out to evaluate whether the risk of acquiring methicillin-resistant Staphylococcus aureus (MRSA) is increased compared to reference data when standard precautions are practiced instead of strict or contact isolation.

Methods

From 2000 through 2005, all patients with MRSA at a university hospital were prospectively surveyed. The isolates were investigated using molecular microbiology methods (PFGE, PCR) and compliance with hand hygiene was indirectly monitored using the consumption of disinfection solutions and glove use as surrogate markers.

Results

The MRSA rates of the 797 patients were lower than for the reference data (PEG, KISS), the incidence of MRSA infections was reduced continuously, MRSA transmissions to contact patients could be demonstrated in about 30%, and the consumption of hand disinfection solutions as well as gloves was significantly higher in 2005 compared to 2000.

Conclusions

There is no evidence from our results that practicing standard precautions would increase the risk for the acquisition of MRSA compared to strict or contact isolation.     

Establishment of a new methicillin resistant staphylococcus aureus animal model of osteomyelitis

Purpose

The increase in methicillin-resistant Staphylococcus aureus (MRSA) infections is currently a major health care problem. Vancomycin is still often the first-line anti-microbiological agent for treating such infections; however, a recent decline in efficacy of vancomycin in MRSA infections has raised concerns and accelerated the search for new antibiotics. The aim of this study was to establish a MRSA peri-implant osteomyelitis animal model for future testing of new anti-microbiological agents under typical MRSA infection conditions.

Methods

Eighteen randomised NZW-rabbits underwent a standardised surgical procedure with the insertion of a femoral bone implant. Animals were then divided into group 1 (MRSA inoculation, no antibiotics; M/N), group 2 (MRSA inoculation, Vancomyin; M/V), and group 3 (no MRSA inoculation, no antibiotics; N/N). The primary study outcome parameters were animal leucocyte count, animal weight, and animal body temperature at one, seven, and 42 days after surgery. Additionally, a histo-morphometrical score was established and adjusted to a modified histological Smeltzer score.

Results

Macroscopic and histo-morphometrical findings showed a peri-implant osteomyelitis in group 1 with both increased acute and chronic infection parameters in M/N, as compared to M/V and N/N, indicating that vancomycin treatment prevented typical morphological changes of MRSA peri-implant osteomyelitis. Similarly, there was a reduction in animal weight and increase in leucocyte count and body temperature in group 1 (each p < 0.005). Vancomycin treatment again resulted in significantly reduced leucocyte count and body temperature, and increased animal body weight.

Conclusions

Here we have established a peri-implant MRSA osteomyelitis model that successfully combined clinical and laboratory outcome parameters of infection with histo-morphometrical results; this model appears to be valuable for future experimental use and therapeutic monitoring of new anti-microbiological MRSA drugs.