Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery

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Surgical site infections (SSIs) are the second most common cause of nosocomial infection.1 SSIs are associated with a prolonged hospital stay and increased re‐hospitalization and mortality rates, as well as additional healthcare costs. In the Australian and New Zealand healthcare systems, between 2 and 13% of hospitalized patients develop a healthcare‐associated infection, of which 20% are SSIs.2 In Australia, healthcare‐associated infection counts for 180 000 patients and 2 million bed days each year. The costs associated with these incidents are significant. In 2003, the cost of healthcare‐associated infections to the New Zealand healthcare system was estimated at NZ$85.26 million,4 and the costs associated with only 126 SSIs in one Australian state were recently reported to be in excess of AU$5 million.5 Infections in surgical sites occur in 1–4% of cardiac surgery patients and are associated with poor outcomes and increased mortality.6 SSIs following total joint replacement procedures are also uncommon (1–3%) but can also have devastating consequences. As infection preventions are relatively inexpensive, costing approximately $20 for each patient, with the avoidance of only a small number of SSIs the intervention will likely be cost‐effective.7
The most commonly isolated pathogen in SSIs is Staphylococcus aureus, usually arising from the patients’ own bacterial flora (from skin, mucous membranes and the gastrointestinal tract).1 Reducing S. aureus SSIs is a target of current clinical practice. Standard practice includes antibiotic prophylaxis with β‐lactam or alternative agent (e.g. cefazolin, clindamycin or vancomycin), provided as a single dose administered at the correct time before preceding the operation. Some hospitals also use an anti‐staphylococcal pre‐theatre bundle. The bundle consists of nasal and/or skin decolonization where topical applications of ointment such as mupirocin are used with or without anti‐bacterial body washes or wipes, usually chlorhexidine, before admission to theatre.1 Although the effectiveness of this bundled approach has been tested in a number of trials and a systematic review,1 published results have been inconsistent and the overall impact of these measures is still unclear.
In this review, we define ‘the patient care bundle’ to be pre‐theatre nasal and/or skin decolonization, in addition to standard care. The aim of this systematic review is to expand the evidence base of an earlier systematic review,1 to assess the effectiveness of bundled prophylaxis in preventing SSI with Gram‐positive bacteria among patients undergoing cardiac or total joint replacement procedures. The results will inform whether the bundled intervention should be adopted as part of a standard SSI prevention protocol.
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