Screening Protocol Detects MRSA Before Open Airway Surgery

February 21, 2012 — Pediatric patients undergoing open airway surgery should be screened for methicillin-resistant Staphylococcus aureus (MRSA) infection to identify patients who would benefit from pre- and perioperative treatment, according to the findings of a retrospective cohort study.

Melissa McCarty Statham, MD, from the Emory University School of Medicine, in Atlanta, Georgia, and colleagues published their findings in the February issue of the Archives of Otolaryngology—Head & Neck Surgery.

"In our experience, MRSA infection in open airway procedures can be a devastating complication, resulting in dehiscence, graft loss, and weakening of the cartilaginous structure of the laryngotracheal complex," the authors write. "Given the high index of suspicion for MRSA in patients undergoing open airway surgery, the development and institution of a screening and treatment antibiotic protocol was essential in proactively managing care of this vulnerable population."

To avoid those devastating complications, Dr. Statham and colleagues tested a preoperative screening procedure in children undergoing open airway surgery, followed by pre-, peri-, and postoperative antibiotic therapy for children positive for MRSA. The authors identified 197 patients who underwent airway surgery at Cincinnati Children's Hospital Medical Center in Ohio from January 2007 to March 2009 for study inclusion; all included patients underwent the previously developed screening protocol.

Of those children, 32.5% of patients were infected with MRSA preoperatively. The most common sites of infection were the nares (43 patients, 79.6% of infected patients) and the bronchoalveolar lavage (27 patients, 50% of infected patients); 66.7% of infected patients were infected in multiple sites. The authors considered patients with a known MRSA infection or a history of MRSA infection without negative cultures to be MRSA-colonized.

MRSA-colonized patients received double-strength trimethoprim-sulfamethoxazole (6 - 12 mg/kg) for 3 days before surgery (clindamycin was given to patients with allergies or resistance to sulfa drugs), and patients who had positive nasal swabs also received intranasal mupirocin twice daily for 3 days before surgery. In addition, patients who were MRSA-colonized received perioperative vancomycin (or another sensitive antibiotic) and postoperative double-strength trimethoprim-sulfamethoxazole for 14 days.

Patients with 3 negative screens were considered MRSA-negative and received either perioperative cephazolin or an alternate antibiotic for children with allergies.

After treatment, the postoperative infection rate was similar between colonized and noncolonized patients (15.9% vs 17.4%, respectively). However, none of the treated patients developed a postoperative MRSA infection compared with 3 patients (2.3%) who were MRSA-negative at preoperative screening.

Adherence to the antibiotic protocol was significantly higher among noncolonized patients, including both complete (63.9% colonized vs 100% noncolonized, respectively; P < .001) and partial (91.8% colonized vs 100% noncolonized, respectively; P = .003) adherence, although intraoperative adherence was high in both groups (93.8% colonized vs 94.0% noncolonized, respectively).

The authors considered patients who were MRSA-colonized to be noncolonized after 3 negative cultures were obtained at least 2 weeks after surgery.

The authors suggest that their findings clarify the need for preoperative MRSA detection and treatment protocols. "Despite the described limitations, our data demonstrate a high prevalence of MRSA in this patient population, suggesting a high risk of postoperative MRSA infection and the need for a MRSA protocol," the authors write. "Future prospective studies in this patient population should further examine postoperative infection rates and specific treatment protocols."

David R. White, MD, from the Medical University of South Carolina in Charleston, agreed with the need for additional mechanisms to improve outcomes among patients undergoing airway surgery. "Airway reconstructive surgery requires a high level of expertise and experience," Dr. White told Medscape Medical News. "Because MRSA has been implicated in surgical failure, anything that can be done to eliminate postoperative infection will be helpful to improve outcomes."

The authors and commentator have disclosed no relevant financial relationships.

Arch Otolaryngol Head Neck Surg. 2012;138:153-157. Abstract