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Publication Briefs

Bundled Intervention Associated with Lower Rates of Surgical Site Infections following Cardiac or Orthopedic Operations

The risk of S. aureus surgical site infections (SSIs) may be decreased by screening patients for S. aureus nasal carriage and decolonizing carriers during the preoperative period. In addition, perioperative prophylaxis may reduce rates of methicillin-resistant S. aureus (MRSA) SSIs. However, surveys in the U.S. indicate that adoption of screening and decolonization bundles varies substantially; in addition, clinicians usually decolonize only those patients carrying MRSA, despite the greater frequency of colonization by methicillin-susceptible S. aureus (MSSA) and the severity of MSSA infections.

This 5-year quasi-experimental study evaluated whether the implementation of an evidence-based bundle is associated with a lower risk of S. aureus SSIs in patients undergoing cardiac operations (n=10,833) or hip or knee arthroplasties (n=31,701). Investigators included 20 non-VA hospitals in 9 states, in which 8 hospitals implemented the intervention bundle for joint arthroplasties, 4 for cardiac operations, and 8 for both categories. Patients in the intervention were screened: if positive for MRSA or MSSA, they applied mupirocin intranasally and bathed daily with chlorhexidine-gluconate (CHG) for 5 days before their operations. MRSA carriers received vancomycin and cefazolin for perioperative prophylaxis; all others received cefazolin. MRSA- and MSSA-negative patients bathed with CHG the night before and morning of their operations. Patients were treated as MRSA-positive if screening results were unknown. Rates of SSIs were then collected for a median of 39 months pre-intervention (3/1/2009 to intervention) and 21 months during the intervention (intervention start to 3/31/2014).


  • Implementation of an SSI prevention bundle was associated with reduced S. aureus SSI rates. During the pre-intervention period, there were 101 complex S. aureus SSIs (45 MRSA, 44 MSSA, and 12 unknown methicillin susceptibility) compared with 29 (14 MRSA, 13 MSSA, and 2 unknown methicillin susceptibility) during the intervention period. Also, the number of months without any complex S. aureus SSIs increased from 2 of 39 (5%) to 8 of 22 (36%)
  • After a 3-month phase-in period, bundle adherence was 83% (39% full; 44% partial). The complex S. aureus SSI rates decreased significantly among patients in the fully adherent group compared with the pre-intervention period (RR = 0.26; 95% CI), but rates did not decrease significantly in the partially adherent or non-adherent group (RR = 0.80; 95% CI).


  • Surveillance for SSI varied somewhat among the hospitals.
  • These study results may not be generalizable to large academic health centers or to hospitals without strong infrastructures for quality improvement.

Dr. Schweizer was supported by an HSR&D Career Development Award and is part of HSR&D's Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA.

PubMed Logo Schweizer M. Chiang H-Y, Septimus E, et al. Association of a Bundled Intervention with Surgical Site Infections among Patients Undergoing Cardiac, Hip or Knee Surgery. JAMA. June 2, 2015;313(21):2162-2171.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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