Skip to main content Accessibility help

Preoperative Nasal Methicillin-Resistant Staphylococcus aureus Status, Surgical Prophylaxis, and Risk-Adjusted Postoperative Outcomes in Veterans

  • Kalpana Gupta (a1) (a2), Judith Strymish (a1) (a3), Youmna Abi-Haidar (a4) (a2), Sandra A. Williams (a5) and Kamal M. F. Itani (a4) (a2)...



To determine whether preoperative nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage is a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis.


Retrospective cohort study.


Veterans Affairs (VA) Boston patients who had nasal MRSA polymerase chain reaction screening performed in the 31 days before clean or clean contaminated surgery in 2008–2009.


Postoperative MRSA clinical cultures and infections, total surgical site infections (SSIs), and surgical prophylaxis data were abstracted from administrative databases. MRSA infections were confirmed via chart review. Multivariate analysis of risk factors for each outcome was conducted using Poisson regression. SSI risk index was calculated for a subset of 1,551 patients assessed by the VA National Surgical Quality Improvement Program.


Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. Postoperative MRSA clinical cultures and infections, including MRSA SSIs, were each significantly increased in patients with preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA remained significantly associated with postoperative MRSA cultures (relative risk [RR], 8.81; 95% confidence interval [CI], 3.01–25.82) and infections (RR, 8.46; 95% CI, 1.70–42.04). Vancomycin prophylaxis was associated with an increased risk of total SSI in those negative for nasal MRSA (RR, 4.34; 95% CI, 2.19–8.57) but not in patients positive for nasal MRSA.


In our population, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures and infections in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients.


Corresponding author

VA Boston HCS, 1400 VFW Parkway, 111 Med, West Roxbury, MA 02132 (


Hide All
1.Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725730.
2.Anderson, DJ, Kaye, KS. Staphylococcal surgical site infections. Infect Dis Clin North Am 2009;23:5372.
3.Anderson, DJ, Kaye, KS, Chen, LF, et al.Clinical and financial outcomes due to methicillin-resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One 2009;4:e8305.
4.Engemann, JJ, Carmeli, Y, Cosgrove, SE, et al.Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592598.
5.Hidron, AI, Edwards, JR, 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;29:9961011.
6.Anderson, DJ, Sexton, DJ, Kanafani, ZA, Auten, G, Kaye, KS. Severe surgical site infection in community hospitals: epidemiology, key procedures, and the changing prevalence of methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2007;28:10471053.
7.Kluytmans, J, van Belkum, A, Verbrugh, H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clinical Microbiol Rev 1997;10:505520.
8.Huang, SS, Yokoe, DS, Hinrichsen, VL, et al.Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 2006;43:971978.
9.Simor, AE, Phillips, E, McGeer, A, et al.Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis 2007;44:178185.
10.Weber, SG, Huang, SS, Oriola, S, et al.Legislative mandates for use of active surveillance cultures to screen for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci: position statement from the Joint SHEA and APIC Task Force. Infect Control Hosp Epidemiol 2007;28:249260.
11.Harbarth, S, Fankhauser, C, Schrenzel, J, et al.Universal screening for MRSA at hospital admission and nosocomial infection in surgical pateints. JAMA 2008;299:11491157.
12.Munoz, P, Hortal, J, Giannella, M, et al.Nasal carriage of S. aureus increases the risk of surgical site infection after major heart surgery. J Hosp Iinfect 2008;68:2531.
13.Bode, LG, Kluytmans, JA, Wertheim, HF, et al.Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:917.
14.Darouiche, RO, Wall, MJ JrItani, KM, et al.Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:1826.
15.Wenzel, RP. Minimizing surgical-site infections. N Engl J Med 2010;362:7577.
16.Perl, TM, Cullen, JJ, Wenzel, RP, et al.Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:18711877.
17.Kalmeijer, MD, Coertjens, H, van Nieuwland-Bollen, PM, et al.Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis 2002;35:353358.
18.Tacconelli, E, De Angelis, G, de Waure, C, Cataldo, MA, La Torre, G, Cauda, R. Rapid screening tests for meticillin-resistant Staphylococcus aureus at hospital admission: systematic review and meta-analysis. Lancet Infect Dis 2009;9:546554.
19.Lucet, JC, Regnier, B. Screening and decolonization: does methicillin-susceptible Staphylococcus aureus hold lessons for methicillin-resistant S. aureus? Clin Infect Dis 2010;51:585590.
20.Peterson, LR, Diekema, DJ. To screen or not to screen for methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2010;48:683689.
21.Diekema, DJ, Climo, M. Preventing MRSA infections: finding it is not enough. JAMA 2008;299:11901192.
22.Calfee, DP, Salgado, CD, Classen, D, et al.Strategies to prevent transmission of methicillin-resistant Staphylococcus aureus in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S62S80.
23.Kim, DH, Spencer, M, Davidson, SM, et al.Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 2010;92:18201826.
24.Schwarzkopf, R, Takemoto, RC, Immerman, I, Slover, JD, Bosco, JA. Prevalence of Staphylococcus aureus colonization in orthopaedic surgeons and their patients: a prospective cohort controlled study. J Bone Joint Surg Am 2010;92:18151819.
25.Chambers, D, Worthy, G, Myers, L, et al.Glycopeptide vs. non-glycopeptide antibiotics for prophylaxis of surgical site infections: a systematic review. Surg Infect (Larchmt) 2010;11:455462.
26.LaPlante, KL, Caffrey, AR, Gupta, K. Prevention of surgical-site infections. N Engl J Med 2010;362:15401541; author reply 1542–1543.
27.Neumayer, L, Hosokawa, P, Itani, K, El-Tamer, M, Henderson, WG, Khuri, SF. Multivariable predictors of postoperative surgical site infection after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007;204:11781187.
28.Lee, BY, Wiringa, AE, Bailey, RR, et al.The economic effect of screening orthopedic surgery patients preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol 2010;31:11301138.
29.Murthy, A, De Angelis, G, Pittet, D, Schrenzel, J, Uckay, I, Harbarth, S. Cost-effectiveness of universal MRSA screening on admission to surgery. Clin Microbiol Infect 2010;16:17471753.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed