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

Published online by Cambridge University Press:  20 September 2018

Susan E. Kline ,
Erinn C. Sanstead ,
James R. Johnson  and
Shalini L. Kulasingam
Susan E. Kline*
Affiliation:
Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
Erinn C. Sanstead
Affiliation:
Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota
James R. Johnson
Affiliation:
Division of Infectious Diseases, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Veterans Affairs Medical Center, Minneapolis, Minnesota
Shalini L. Kulasingam
Affiliation:
Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota
*
Author for correspondence: Susan Kline MD, MPH, 420 Delaware St SE, MMC# 250, Minneapolis, MN 55455. E-mail: [email protected]
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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.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 11 , November 2018 , pp. 1340 - 1346
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

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References

1. Hidron, A, Edwards, J, Patel, J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007. Infect Control Hosp Epidemiol 2008;29:996–1011.Google Scholar
2. Perl, TM, Golub, JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother 1998;32:S7–S16.Google Scholar
3. Wenzel, RP, Perl, TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infections. J Hosp Infect 1995;31:13–24.Google Scholar
4. Ban, KA, Minei, JP, Laronga, C, et al. American college of surgeons and surgical infection society: surgical site infection guidelines, 2016 update. Am Coll Surg 2017;224:59–74.Google Scholar
5. Global guidelines for the prevention of surgical site infection. World Health Organization website. http://www.who.int/gpsc/ssi-guidelines/en/. Published 2016. Accessed July 21, 2017.Google Scholar
6. Parvizi, J, Shohat, N, Gehrke, T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J 2017;99-B 4 Supple B:3–10.Google Scholar
7. Berríos-Torres, SI, Umscheid, CA, Bratzler, DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–791.Google Scholar
8. Chlebicki, M, Safdar, N, O’Horo, JC. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control 2013;41:167–173.Google Scholar
9. Botelho-Nevers, E, Gagnaire, J, Verhoeven, PO, et al. Decolonization of Staphylococcus aureus carriage in 2016. Med Mal Infect 2016:1–6.Google Scholar
10. Courville, XF, Tomek, IM, Kirkland, KB, et al. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2012:33:152–159.Google Scholar
11. Wassenberg, MWM, Wit, GA De, Bonten, MJM. Cost-effectiveness of preoperative screening and eradication of Staphylococcus aureus carriage. PLoS One 2011;6:e14815.Google Scholar
12. Young, LS, Winston, LG. Preoperative use of mupirocin for the prevention of healthcare-associated Staphylococcus aureus infections: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 2006;27:1304–1312.Google Scholar
13. Noskin, GA, Rubin, RJ, Schentag, JJ, et al. Budget impact analysis of rapid screening for Staphylococcus aureus colonization among patients undergoing elective surgery in US hospitals. Infect Control Hosp Epidemiol 2008;29:16–24.Google Scholar
14. Kline, S, Neaton, J, Lynfield, R, et al. Effectiveness of screening and decolonization of S. aureus in surgery outpatients. Infect Control Hosp Epidemiol 2018 Jul 24:1–9. doi: 10.1017/ice.2018.151. Google Scholar
15. Magill, S, Edwards, J, Bamberg, W, et al. Multistate point-prevalence survey of health care-associated infections. Nat Rev Microbiol 2014;370:1198–1208.Google Scholar
16. Luteijn, JM, Hubben, GAA, Pechlivanoglou, P, et al. Diagnostic accuracy of culture-based and PCR-based detection tests for methicillin-resistant Staphylococcus aureus: a meta-analysis. Clin Microbiol Infect 2010;17:146–154.Google Scholar
17. Miller, RR, Walker, AS, Godwin, H, et al. Dynamics of acquisition and loss of carriage of Staphylococcus aureus strains in the community: the effect of clonal complex. J Infect 2014;68:426–439.Google Scholar
18. Jalal, H, Alarid-Escudero, F, Hunink, MGM. PS 1-58 DTree: an open source tool for building decision trees and cost-effectiveness analyses. In: 38th Annual North American Meeting of the Society for Medical Decision Making; 2016:E57.Google Scholar
19. Wertheim, HFL, Melles, DC, Vos, MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis 2005;5:751–762.Google Scholar
20. Simor, AE. Staphylococcal decolonization: an effective strategy for prevention of infection? Lancet Infect Dis 2011;11:952–962.Google Scholar
21. Bode, L, Kluytmans, J, W, H, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus . N Engl J Med 2010;362:9–17.Google Scholar
22. Occupational outlook handbook, 2016–2017. US Department of Labor Bureau of Labor Statistics website. https://www.bls.gov/ooh/healthcare/registered-nurses.htm. Published 2017. Accessed August 1, 2017.Google Scholar
23. Berger, A, Edelsberg, J, Yu, H, et al. Clinical and economic consequences of post-operative infections following major elective surgery in US hospitals. Surg Infect (Larchmt) 2014;15:322–327.Google Scholar
24. CPI inflation calculator. US Department of Labor Bureau of Labor Statistics website. https://data.bls.gov/cgi-bin/cpicalc.pl. Accessed August 23, 2018.Google Scholar
25. Gillian, S, Neiumann, P, Basu, A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA 2016;316:1093–1103.Google Scholar
26. Emohare, O, Ledonio, CG, Hill, BW, et al. Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery. Spine J 2014;14:2710–2715.Google Scholar
27. Kurtz, SM, Lau, E, Watson, H, et al. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:61–65.Google Scholar
28. Tong, SYC, Davis, JS, Eichenberger, E, et al. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015;28:603–661.Google Scholar
29. Urban, JA. Cost analysis of surgical site infections. Surg Infect (Larchmt) 2006;7:19–22.Google Scholar
30. Kirkland, KB, Briggs, JP, Trivette, SL, et al. The impact of surgical-site infections in the 1990’s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725–730.Google Scholar
31. Perl, TM, Cullen, JJ, Wenzel, RP. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infection. New Engl J Med 2002;346:1871–1877.Google Scholar
32. Segers, P, Speekenbrink, R, Ubbink, D, et al. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate a randomized controlled trial. JAMA 2006;296:2460–2466.Google Scholar
33. Kluytmans, JA, Mouton, JW, Marjolein, FQ. Reduction of surgical site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus . Infect Control Hosp Epidemiol 1996;17:780–784.Google Scholar
34. Schweizer, ML, Chiang, H, Septimus, E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015;313:2162–2171.Google Scholar
35. Kalmeijer, MD, Coertjens, H, van Nieuwland-Bollen, PM. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis 2002;35:353–358.Google Scholar
36. Konvalink, A, Erret, L, Fong, IW. Impact of treating Staphylococcus aureus nasal carriage on wound infections in cardiac surgery. J Hosp Infect 2006;64:162–168.Google Scholar
37. Irish, D, Eltringham, I, Teall, A, et al. Control of an outbreak of an epidemic methicillin-resistant Staphylococcus aureus also resistant to mupirocin. J Hosp Infect 1998;39:19–26.Google Scholar
38. Hayden, MK, Lolans, K, Haffenreffer, K, et al. Chlorhexidine and mupirocin susceptibility of methicillin-resistant Staphylococcus aureus isolates in the REDUCE-MRSA trial. J Clin Microbiol 2016;54:2735–2742.Google Scholar
39. Noskin, GA, Rubin, RJ, Schentag, JJ, et al. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998–2003). Clin Infect Dis 2007;45:1132–1140.Google Scholar