Pre-Surgery “Treat-All” Approach Works Best for Preventing Staph Infections

A regimen of using antibacterial showers, mouthwash and nasal ointment preparations before surgery for all adult patients is more effective and cost-saving compared with only treating patients who test positive for Staphylococcus aureus (SA), or providing usual care consisting of disinfectant soap showers, according to a new AHRQ-supported study in Infection Control and Hospital Epidemiology. The analysis, based partly on data from an AHRQ-supported randomized trial, found that the "treat-all" approach resulted in the fewest surgical site infections and the lowest costs compared with only treating those who tested positive for SA or only received usual care. Compared with usual care, estimated savings for each surgical site infection prevented were $21,929 for "treat-all" and $15,166 for "test-and-treat." Researchers recommended future clinical trials should more fully quantify comparative benefits and harms associated with the different infection prevention strategies. Access the abstract.

2018 Nov;39(11):1340-1346. doi: 10.1017/ice.2018.228. Epub 2018 Sep 20.

Cost-effectiveness of pre-operative Staphylococcus aureus screening and decolonization.

Kline SE1, Sanstead EC2, Johnson JR1, Kulasingam SL2.

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Abstract

OBJECTIVE:

We developed a decision analytic model to evaluate the impact of a preoperative Staphylococcus aureus decolonization bundle on surgical site infections (SSIs), health-care-associated costs (HCACs), and deaths due to SSI.

METHODS:

Our model population comprised US adults undergoing elective surgery. We evaluated 3 self-administered preoperative strategies: (1) the standard of care (SOC) consisting of 2 disinfectant soap showers; (2) the "test-and-treat" strategy consisting of the decolonization bundle including chlorhexidine gluconate (CHG) soap, CHG mouth rinse, and mupirocin nasal ointment for 5 days) if S. aureus was found at any of 4 screened sites (nasal, throat, axillary, perianal area), otherwise the SOC; and (3) the "treat-all" strategy consisting of the decolonization bundle for all patients, without S. aureus screening. Model parameters were derived primarily from a randomized controlled trial that measured the efficacy of the decolonization bundle for eradicating S. aureus.

RESULTS:

Under base-case assumptions, the treat-all strategy yielded the fewest SSIs and the lowest HCACs, followed by the test-and-treat strategy. In contrast, the SOC yielded the most SSIs and the highest HCACs. Consequently, relative to the SOC, the average savings per operation was $217 for the treat-all strategy and $123 for the test-and-treat strategy, and the average savings per per SSI prevented was $21,929 for the treat-all strategy and $15,166 for the test-and-treat strategy. All strategies were sensitive to the probability of acquiring an SSI and the increased risk if SSI if the patient was colonized with SA.

CONCLUSION:

We predict that the treat-all strategy would be the most effective and cost-saving strategy for preventing SSIs. However, because this strategy might select more extensively for mupirocin-resistant S. aureus and cause more medication adverse effects than the test-and-treat approach or the SOC, additional studies are needed to define its comparative benefits and harms.