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      Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques : One third of carriers missed

      , MBChB, BSc (Hons), MSc, MRCSEd , 1 , , BSc (Hons), MSc 2 , , BSc (Hons), MSc 2 , , BSc (Hons), PhD 3 , , BSc (Hons), PhD 4 , , BA, BM, BCh, MA, FRCSEd, DM 5 , , BSc (Hons), MBChB (Hons), FRCA, MD, MRes, FFICM 6 , , MBChB, MD, FRCPath 2 , , BSc (Hons), PhD, FRCPath 2

      Bone & Joint Research

      Surgical site infection, Staphylococcus aureus, Periprosthetic joint infection

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          Abstract

          Objectives

          Nasal carriers of Staphylococcus (S.) aureus ( MRSA and MSSA) have an increased risk for healthcare-associated infections. There are currently limited national screening policies for the detection of S. aureus despite the World Health Organization’s recommendations. This study aimed to evaluate the diagnostic performance of molecular and culture techniques in S. aureus screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on S. aureus detection in orthopaedic patients.

          Methods

          Paired nasal swabs for polymerase chain reaction (PCR) assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint arthroplasty surgery.

          Results

          The prevalence of MSSA nasal colonization was found to be between 22.4% to 35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p = 0.005), failing to identify its presence in approximately one-third of patients undergoing joint arthroplasty surgery.

          Conclusion

          Modelling these results to national surveillance data, it was estimated that approximately 5000 to 8000 S. aureus surgical site infections could be prevented, and approximately $140 million to $950 million (approximately £110 million to £760 million) saved in treatment costs annually in the United States and United Kingdom combined, by using alternative diagnostic methods to direct culture in preoperative S. aureus screening and eradication programmes.

          Cite this article: S. T. J. Tsang, M. P. McHugh, D. Guerendiain, P. J. Gwynne, J. Boyd, A. H. R. W. Simpson, T. S. Walsh, I. F. Laurenson, K. E. Templeton. Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques: One third of carriers missed. Bone Joint Res 2018;7:79–84. DOI: 10.1302/2046-3758.71.BJR-2017-0175.R1.

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          Most cited references 33

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          Preventing surgical-site infections in nasal carriers of Staphylococcus aureus.

          Nasal carriers of Staphylococcus aureus are at increased risk for health care-associated infections with this organism. Decolonization of nasal and extranasal sites on hospital admission may reduce this risk. In a randomized, double-blind, placebo-controlled, multicenter trial, we assessed whether rapid identification of S. aureus nasal carriers by means of a real-time polymerase-chain-reaction (PCR) assay, followed by treatment with mupirocin nasal ointment and chlorhexidine soap, reduces the risk of hospital-associated S. aureus infection. From October 2005 through June 2007, a total of 6771 patients were screened on admission. A total of 1270 nasal swabs from 1251 patients were positive for S. aureus. We enrolled 917 of these patients in the intention-to-treat analysis, of whom 808 (88.1%) underwent a surgical procedure. All the S. aureus strains identified on PCR assay were susceptible to methicillin and mupirocin. The rate of S. aureus infection was 3.4% (17 of 504 patients) in the mupirocin-chlorhexidine group, as compared with 7.7% (32 of 413 patients) in the placebo group (relative risk of infection, 0.42; 95% confidence interval [CI], 0.23 to 0.75). The effect of mupirocin-chlorhexidine treatment was most pronounced for deep surgical-site infections (relative risk, 0.21; 95% CI, 0.07 to 0.62). There was no significant difference in all-cause in-hospital mortality between the two groups. The time to the onset of nosocomial infection was shorter in the placebo group than in the mupirocin-chlorhexidine group (P=0.005). The number of surgical-site S. aureus infections acquired in the hospital can be reduced by rapid screening and decolonizing of nasal carriers of S. aureus on admission. (Current Controlled Trials number, ISRCTN56186788.) 2010 Massachusetts Medical Society
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            The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost.

            To measure the impact of orthopedic surgical-site infections (SSIs) on quality of life, length of hospitalization, and cost. A pairwise-matched (1:1) case-control study within a cohort. A tertiary-care university medical center and a community hospital. Cases of orthopedic SSIs were prospectively identified by infection control professionals. Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI. Matching variables included type of surgical procedure, National Nosocomial Infections Surveillance risk index, age, date of surgery, and surgeon. Quality of life, duration of postoperative hospital stay, frequency of hospital readmission, overall direct medical costs, and mortality rate. Fifty-nine SSIs were identified. Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization (P = .001) and a median of 14 extra days of hospitalization during the follow-up period (P = .0001). Patients with SSI required more rehospitalizations (median, 2 vs 1; P = .0001) and more total surgical procedures (median, 2 vs 1; P = .0001). The median total direct cost of hospitalizations per infected patient was $24,344, compared with $6,636 per uninfected patient (P = .0001). Mortality rates were similar for cases and controls. Quality of life was adversely affected for patients with SSI. The largest decrements in scores on the Medical Outcome Study Short Form 36 questionnaire were seen in the physical functioning and role-physical domains. Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life.
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              Prosthetic joint infection risk after TKA in the Medicare population.

              The current risk of infection in contemporary total knee arthroplasty (TKA) as well as the relative importance of risk factors remains under debate as a result of the rarity of the complication and temporal changes in the treatment and prevention of infection. We therefore determined infection incidence and risk factors after TKA in the Medicare population. The Medicare 5% national sample administrative data set was used to identify and longitudinally follow patients undergoing TKA for deep infections and revision surgery between 1997 and 2006. Cox regression was used to evaluate patient and hospital characteristics. In 69,663 patients undergoing elective TKA, 1400 TKA infections were identified. Infection incidence within 2 years was 1.55%. The incidence between 2 and up to 10 years was 0.46%. Women had a lower risk of infection than men. Comorbidities also increased TKA infection risk. Patients receiving public assistance for Medicare premiums were at increased risk for periprosthetic joint infection (PJI). Hospital factors did not predict an increased risk of infection. PJI occurs at a relatively high rate in Medicare patients with the greatest risk of PJI within the first 2 years after surgery; however, approximately one-fourth of all PJIs occur after 2 years. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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                Author and article information

                Contributors
                Role: Clinical Research Fellow
                Role: Clinical Scientist
                Role: Clinical Scientist
                Role: Postdoctoral Research Associate
                Role: Clinical Trials Manager
                Role: George Harrison Law Professor of Orthopaedic Surgery
                Role: Professor of Anaesthesia
                Role: Consultant Medical Microbiologist
                Role: Consultant Clinical Scientist in Microbiology
                Journal
                Bone Joint Res
                Bone & Joint Research
                2046-3758
                January 2018
                8 February 2018
                : 7
                : 1
                : 79-84
                Affiliations
                [1 ]Department of Orthopaedic Surgery, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK and School of Biological Sciences, University of Edinburgh, King’s Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
                [2 ]Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
                [3 ]School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
                [4 ]Edinburgh Clinical Trials Unit, University of Edinburgh (Usher Institute), Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX
                [5 ]Department of Orthopaedic Surgery, Critical care and Pain Medicine, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
                [6 ]Critical care and Pain Medicine, Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
                Author notes
                S. T. J. Tsang; email: jerry.tsang@ 123456ed.ac.uk
                Article
                10.1302_2046-3758.71.BJR-2017-0175.R1
                10.1302/2046-3758.71.BJR-2017-0175.R1
                5805824
                29330346
                © 2018 Tsang et al.

                This is an open-access article distributed under the terms of the Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

                Categories
                Infection
                10
                Surgical Site Infection
                Staphylococcus Aureus
                Periprosthetic Joint Infection

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