Study: SSI bundle lowers the risk of infections for joint and cardiac surgeries

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Study: SSI bundle lowers the risk of infections for joint and cardiac surgeries

A bundled approach can prevent devastating infections


Surgical bundles have become commonplace in the healthcare industry, particularly to help stave off dangerous infections. A recent study looking specifically at cardiac procedures and joint replacement procedures shows that a previously untested surgical site infection (SSI) bundle can offer an additional element of prevention as hospitals strive to reduce infection rates.

The study, published in June by the Journal of the American Medical Association (JAMA), found that a bundled approach to SSI prevention in which patients who tested positive for methicillin-resistant staph aureus (MRSA) and methicillin-susceptible staph aureus (MSSA) applied mupirocin intranasally twice a day five days prior to surgery and bathed in chlorhexidine-gluconate for five days prior to surgery. The treatment can reduce complex SSIs anywhere from 40% to 75% depending on adherence. Patients that tested positive for MRSA or MSSA were also given vancomycin and cefazolin prior to surgery.

Loreen Herwaldt, MD, a professor of infectious diseases at the University of Iowa College of Medicine, a hospital epidemiologist at the University of Iowa Hospitals and Clinics in Iowa City, and the lead author of the study, said that elements of the bundle have been previously studied separately, but no one had looked at all of the elements bundled together.

"Staph aureus is a very common cause of infections for these procedures, and if these patients get infected, if it's a joint replacement, they could lose the joint," she says. "In the best case scenario, they could be treated for probably a couple of months with IV antibiotics. And you can imagine how serious an infection in the bone of the sternum or in the tissue around the heart could be. So the goal is to prevent those infections."

The study took place in 20 Hospital Corporation of America (HSA) hospitals, which already had low SSI rates, in part because they were already doing isolated elements of the bundle. Even a marginal SSI reduction speaks volumes about the potential of the bundle, particularly in facilities with a higher SSI rate, says Preeti Malani, MD, an infectious disease professor at the University of Michigan Health System in Ann Arbor, Michigan and an associate editor at JAMA who wrote the editorial that accompanied the article.

Malani adds that hospitals are under incredible pressure to achieve zero infections, particularly with SSIs that are expensive and dangerous. This bundle offers another effective approach in addressing joint and cardiac procedures.

"I think this fits in as one more piece of an overall approach," she says.

Both Malani and Herwaldt say that some of their infectious disease colleagues push back against the use of unnecessary antibiotics like mupirocin, and the continuous use of chlorhexidine, citing concerns of resistance. Herwaldt says that other researchers have looked at the use of iodine applied intranasally to every patient prior to surgery, but that it's still too early to adequately understand the effectiveness of that approach.

However, Malani says the risk-reward is worth it, particularly for complex SSIs that can be devastating.

"If someone actually gets an infection, you're talking about six to eight weeks of antibiotics," she says. "There is that thought that you're increasing use overall in terms of the number of people that are exposed, but if you think about saving 15 infections per 10,000 operations, that's a lot of doses."