Perioperative management of neurosurgical patients with methicillin-resistant Staphylococcus aureus

Clinical article

Paul T. Akins Department of Neurosurgery, Kaiser Permanente, Sacramento; and
Department of Neurosurgery, University of California San Francisco, California

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 M.D., Ph.D.
,
John Belko Department of Neurosurgery, Kaiser Permanente, Sacramento; and

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 M.D.
,
Amit Banerjee Department of Neurosurgery, Kaiser Permanente, Sacramento; and

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 M.D.
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Kern Guppy Department of Neurosurgery, Kaiser Permanente, Sacramento; and
Department of Neurosurgery, University of California San Francisco, California

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 M.D., Ph.D.
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David Herbert Department of Neurosurgery, Kaiser Permanente, Sacramento; and

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 M.D.
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Tamara Slipchenko Department of Neurosurgery, Kaiser Permanente, Sacramento; and

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 Ph.D.
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Christi DeLemos Department of Neurosurgery, Kaiser Permanente, Sacramento; and

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 N.P.
, and
Mark Hawk Department of Neurosurgery, Kaiser Permanente, Sacramento; and
Department of Neurosurgery, University of California San Francisco, California

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 M.D.
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Object

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has posed a challenge in the treatment of neurosurgical patients. The authors investigated the impact of MRSA colonization and infection in the neurosurgical population at a community-based, tertiary care referral center.

Methods

Hospitalized patients under the care of the Kaiser Permanente inpatient neurosurgery service were prospectively entered into a database. In Phase I of the study, 492 consecutive patients were followed. Per hospital policy, the 260 patients from this group who were admitted to the intensive care unit (ICU) underwent screening for MRSA based on nasal swab cultures and a review of their medical history for prior MRSA infections. These patients were designated as either MRSA positive (17 patients, 6.5% of screened patients) or MRSA negative (243 patients). The 232 patients admitted to non-ICU nursing units did not undergo MRSA screening and were designated as unscreened. In Phase II of the study, the authors reviewed 1005 neurosurgical admissions and completed a detailed chart review in 62 MRSA-positive patients (6.2%). Eleven patients received nonoperative treatment. Five patients presented with community-acquired neurosurgical infections, and the causative organism was MRSA in 3 cases. Forty-six patients underwent 55 procedures, and the authors reviewed their perioperative management.

Results

In Phase I of the study, the authors found that for the MRSA-positive, MRSA-negative, and unscreened groups, the rates of postoperative neurosurgical wound infections caused by all pathogens were 23.5, 4.1, and 1.3%, respectively. For MRSA wound infections, the rates were 23.5, 0.8, and 0%, respectively. In Phase II, patients with MRSA were noted to have the following clinical features: male sex in 63%, a malignancy in 39.1%, diabetes in 34.8%, prior MRSA infection in 21.7%, immunosuppressed state in 17.4%, and a traumatic injury in 15.2%. The rate of postoperative neurosurgical wound infection in patients who received MRSA-specific prophylactic antibiotic therapy (usually vancomycin) was 7.4% (27 procedures) compared with 32.1% (28 procedures) in patients who received the standard treatment (usually cefazolin) (p = 0.04). Wound care for ICU patients was standardized for postoperative Days 0–7 with chlorhexidine cleaning at bandage changes at 3-day intervals. Wound cultures from neurosurgical site infections in patients with prior MRSA colonization or infection grew MRSA in 7 of 11 patients.

Conclusions

Neurosurgical patients identified with MRSA colonization or a prior history of MRSA infections benefit from specific perioperative care, including prophylactic antibiotics active against MRSA (such as vancomycin) and postoperative wound care with coverings and chlorhexidine antisepsis to reduce MRSA wound colonization.

Abbreviations used in this paper:

ICU = intensive care unit; MRSA = methicillin-resistant Staphylococcus aureus; RR = relative risk.
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