Staff Nurse, Infection Prevention Coordinator Boston Children's Hospital Melrose, Massachusetts, United States
Abstract:
Introduction: Staphylococcus aureus (SA) colonization increases the risk of surgical site infection (SSI) in adult cardiac and orthopedic populations. Evidence supports pre-operative screening and decolonization for SA carriage to reduce the risk of infection. In 2017, our pediatric cardiac intensive care unit adopted this practice for inpatients prior to cardiac surgery. The intent was to administer at least four doses of mupirocin, prior to surgical intervention, while awaiting nasal screening results. We observed a reduction in SSI caused by SA in the treatment group, but patients admitted on the day of surgery continued to experience SSI caused by SA. The purpose of this project was to expand screening and decolonization to all cardiac surgery patients.
Methods: An interdisciplinary group with representation from all Heart Center clinical areas convened to develop strategies to capture all cardiac surgery patients in the decolonization process. Several obstacles made it challenging to implement the existing screening and decolonization practice in outpatients. Therefore, alternative solutions were explored to facilitate inclusion of all cardiac surgery patients. Based on evidence from adult populations demonstrating that nasal application of povidone-iodine suppresses SA in the nares for up to 12 hours and may reduce SSI, we instituted an innovative change in practice. Beginning January 2020, all cardiac surgery patients underwent screening for nasal SA carriage pre-operatively and received nasal decolonization with povidone-iodine (unless allergic) prior to incision. If screening demonstrates SA carriage, patients are decolonized using intranasal mupirocin for five days; daily chlorhexidine bathing for five days is added if the patient is > 2 months of age. Compliance with SA screening and decolonization were compared pre- vs. post-intervention. SSI were identified prospectively using Society of Thoracic Surgeons definitions.
Results: Prior to the intervention, 1055 (57%) of 1851 eligible patients completed intended SA screening, compared with 1975 (87%) of 2274 patients after the intervention. Pre-intervention, 659 (36%) of 1851 patients received four or more doses of mupirocin prior to incision. In the post-intervention period, 2161 (95%) of 2263 eligible patients received povidone-iodine nasal decolonization. The annual number of SSI caused by SA decreased from 9 in 2016 to 3 in 2021 (Figure 1).
Conclusion: Initiation of pre-operative nasal decolonization using povidone-iodine and expansion of eligibility to include all cardiac surgery patients has been a successful initiative in our program. We observed an increase in the proportion of eligible patients who undergo decolonization as intended, which was accompanied by a continued reduction in SSI caused by SA.
