MRSA and MSSA in Patients Undergoing Plastic Surgery: Prevalence in 3779 Patients and Implementation of a Surveillance and Surgical Site Infection Reduction Protocol
PURPOSE: Surgical site infections (SSI) are a common complication after surgery with a potential for high morbidity and additional healthcare resource utilization that, in the near future, may not be reimbursed for by third-party payers. A screening protocol for methicillin sensitive Staphylococcus aureus (MSSA) and methicillin resistant Staphylococcus aureus (MRSA ) has been shown to reduce SSI. Over the past 3 years, a large-scale expanded surveillance program for MRSA and MSSA was implemented at our institution.  The compliance to this program by the plastic surgery service is evaluated in this study.

METHODS & MATERIALS: A retrospective review of a SSI and MRSA/MSSA database of an academically affiliated 3-hospital organization (850-beds, 40,000 annual admissions). The institution has two surveillance programs: 1) preoperative surveillance by nasal swab polymerase chain reaction (PCR) for all S. aureus (i.e. MRSA or MSSA) and 2) universal admission surveillance by nasal swab for MRSA only.  All S. aureus carriers are decolonized and contact isolation is additionally employed for patients who test positive for MRSA. All MRSA isolates are further tested by PCR for the presence of genes encoding the Panton Valentine Leukocidin (PVL), a marker of community-associated MRSA.  Patients were prospectively followed for deep SSI.

RESULTS: Of 3779 study patients, 2179 (57.7%) were screened preoperatively by either nasal PCR test, but only 1425 (37.7%) were tested for all S. aureus (23.7% in 2006, 38.3% in 2007 and 51.5% in 2008). Of the 2179 patients 89 (4.1%) were MRSA positive.  Of the 1425 patients tested for both MRSA and MSSA 228 (16.0%) were MSSA positive. Only 4 (0.2%) patients had mupirocin resistant MRSA or MSSA. By PVL testing, only 6 (0.3%) patients had community-associated MRSA. A total of 62 (1.6%) non-superficial SSI were identified, 5 of which were caused by MRSA.  Only one of these patients was found to be an MRSA carrier preoperatively.

CONCLUSIONS: MRSA is an uncommon pathogen in SSI in a center where extensive MRSA surveillance takes place. Here, we have found that :

1. Initial compliance with the institutional surveillance program was not high, but appears to be progressively improving.
2. Plastic surgery patients have a distinct prevalence of MRSA colonization on admission.
3. As pre-operative MRSA colonization is known to predispose surgical patients to SSI, decolonization should be considered.