Infection Control & Hospital Epidemiology

Original Article

Preoperative Nasal Methicillin-Resistant Staphylococcus aureus Status, Surgical Prophylaxis, and Risk-Adjusted Postoperative Outcomes in Veterans

Kalpana Guptaa1a4 c1, Judith Strymisha1a5, Youmna Abi-Haidara2a4, Sandra A. Williamsa3 and Kamal M. F. Itania2a4

a1 Department of Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts

a2 Department of Surgery, Veterans Affairs Boston Healthcare System, Boston, Massachusetts

a3 Center for Organization, Leadership, and Management Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts

a4 Boston University School of Medicine, Boston, Massachusetts

a5 Harvard Medical School, Boston, Massachusetts

Abstract

Objectives. To determine whether preoperative nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage is a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis.

Design. Retrospective cohort study.

Patients. Veterans Affairs (VA) Boston patients who had nasal MRSA polymerase chain reaction screening performed in the 31 days before clean or clean contaminated surgery in 2008–2009.

Methods. Postoperative MRSA clinical cultures and infections, total surgical site infections (SSIs), and surgical prophylaxis data were abstracted from administrative databases. MRSA infections were confirmed via chart review. Multivariate analysis of risk factors for each outcome was conducted using Poisson regression. SSI risk index was calculated for a subset of 1,551 patients assessed by the VA National Surgical Quality Improvement Program.

Results. Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. Postoperative MRSA clinical cultures and infections, including MRSA SSIs, were each significantly increased in patients with preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA remained significantly associated with postoperative MRSA cultures (relative risk [RR], 8.81; 95% confidence interval [CI], 3.01–25.82) and infections (RR, 8.46; 95% CI, 1.70–42.04). Vancomycin prophylaxis was associated with an increased risk of total SSI in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19–8.57) but not in patients positive for nasal MRSA.

Conclusions. In our population, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures and infections in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients.

(Received November 30 2010)

(Accepted February 18 2011)

Correspondence

c1 VA Boston HCS, 1400 VFW Parkway, 111 Med, West Roxbury, MA 02132 (kalpana.gupta@va.gov)