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To test the hypothesis that perioperative elimination of nasal carriage of Staphylococcus aureus using mupirocin nasal ointment reduces the surgical-site infection (SSI) rate in cardiothoracic surgery.
Unblinded intervention trial with historical controls.
A university hospital, tertiary referral center for cardiothoracic surgery.
Consecutive patients undergoing cardiothoracic surgery between August 1, 1989, and February 1, 1991 (historical control group), and between March 1, 1991, and August 1, 1992 (intervention group).
The historical control group consisted of 928 patients and the intervention group of 868, of whom 752 actually were treated. The 116 patients who were unintentionally not treated were considered as a concurrent control group. In the intention-to-treat analysis, a significant reduction in SSI rate was observed after the intervention (historical-control group 7.3% and intervention group 2.8%; P<.0001). The SSI rate in the concurrent control group was significantly higher than in the treated group (7.8% and 2.0%, respectively; P=.0023). Resistance of S aureus to mupirocin was not observed.
The results of this study indicate that perioperative elimination of nasal carriage using mupirocin nasal ointment significantly reduces the SSI rate in cardiothoracic surgery patients and warrants a prospective, randomized, placebo-controlled efficacy trial. This preventive measure may be beneficial in other categories of surgical patients as well.
To assess the cost-effectiveness of perioperative intranasal application of mupirocin calcium ointment in cardiothoracic surgery.
Cost-effectiveness analysis based on results of an intervention study with historical controls.
University Hospital Rotterdam, a tertiary referral center for cardiac and pulmonary surgery.
Consecutive patients undergoing cardiothoracic surgery between August 1, 1989, and February 1, 1991 (control group, n=928), and between March 1, 1991, and August 1, 1992 (intervention group, n=868).
Perioperative nasal application of mupirocin calcium ointment started on the day before surgery, continued for 5 days, twice daily.
Postoperative costs were increased significantly in patients with a surgical-site infection (SSI), compared with uninfected patients (P<.001). Mean SSI-attributable costs were estimated at $16,878 (95% confidence interval, $15,575-$18,181). The incidence of SSIs was 7.3% in the control group and 2.8% in the intervention group, mupirocin effectiveness being 62%. The costs of mupirocin were $11 per patient. Thus, the savings per SSI prevented were $16,633. To validate this comparative estimate of SSI-attributable costs, a noncomparative analysis of the postoperative length of stay (POLS) was performed, according to the Appropriateness Evaluation Protocol. Approximately 50% of the comparative SSI-attributable POLS were judged SSI-attributable in the noncomparative analysis. Sensitivity analyses, testing for the robustness of our conclusions, indicated that the presented model is rather insensitive to variations in the incidence of SSIs and for the effectiveness and costs of mupirocin. SSI-attributable costs were shown to be the only variable with substantial effect on the cost-effectiveness ratio. Perioperative mupirocin would result in net costs instead of savings only if SSI-attributable costs were less than $245.
SSIs in patients undergoing cardiothoracic surgery are associated with a substantial increase in postoperative costs. Provided that perioperative mupirocin reduces the SSI rate, this measure will be highly cost-effective in most centers providing cardiothoracic surgical services.
To study the efficacy of mupirocin for the elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients.
The efficacy of mupirocin was studied in a prospectively followed cohort. The effect of this intervention on the rate of S aureus bacteremia was evaluated using a historic control group.
Patients on the hemodialysis unit of the University Hospital Rotterdam, a tertiary referral center.
The study group consisted of consecutive patients on hemodialysis from February 1, 1992, until November 1, 1993. They were screened by taking nasal cultures monthly during their time on hemodialysis. If S aureus was isolated, treatment with mupirocin nasal ointment was initiated. The control group consisted of patients treated on the same hemodialysis unit from January 1, 1990, until January 1, 1992.
The study group consisted of 226 patients, of whom 172 were evaluated to determine the efficacy of mupirocin. Sixty-seven (39%) were identified as nasal carriers. Following the initial treatment, 66 nasal cultures (98.5%) became negative. After 3 months and 6 months, respectively, 63 (94%) and 61 (91%) of the treated carriers had negative cultures. The rate of bacteremia (defined as the number of episodes of 5 aureus bacteremia per patient-year on hemodialysis) was significantly lower among the 226 patients in the study group (0.04 per patient-year) than among the 273 patients in the control group (0.25 per patient year; P <.001). Development of resistance and adverse effects were not observed.
Mupirocin nasal ointment effectively eliminates nasal carriage of 5 aureus in patients on hemodialysis. This was associated with a significant reduction of the incidence of 5 aureus bacteremia, as compared to historic controls.
To report an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in our burn unit and the steps we used to eradicate the organism.
Design And Setting:
Outbreak investigation in the burn unit of a 900-bed tertiary-care medical center.
Between March and June 1993, MRSA was isolated from 10 patients in our burn unit. All isolates had identical antibiograms and chromosomal DNA patterns.
Infection control personnel encouraged healthcare workers to wash their hands after each patient contact. The unit cohorted all infected or colonized patients, placed each affected patient in isolation, and, if possible, transferred the patient to another unit. Despite these measures, new cases occurred. Infection control personnel obtained nares cultures from 56 healthcare workers, 3 of whom carried the epidemic MRSA strain. One healthcare worker cared for six affected patients, and one cared for five patients. We treated the three healthcare workers with mupirocin. Subsequently, no additional patients became colonized or infected with the epidemic MRSA strain.
The outbreak ended after we treated healthcare workers who carried the epidemic strain with mupirocin. This approach is not appropriate in all settings. However, we felt it was justified in this case because of a persistent problem after less intrusive measures.
To determine the impact of three needleless intravenous systems on needlestick injury rates.
Randomized controlled trial.
1,000-bed tertiary-care Midwestern hospital.
Nursing personnel from general medical, general surgical, and intensive-care units.
From June 1992 through March 1994, a metal blunt cannula (MBC), two-way valve (2-way), and plastic blunt cannula (PBC) were introduced into three study areas, and needlestick injury rates were compared to three control areas using traditional needled devices.
24 and 29 needlestick injuries were reported in study and control areas. Intravenous-therapy-related injuries comprised 45.8% and 57.1% of injuries in each area. Thirty-seven percent and 20.7% of study and control area needlestick injuries were considered to pose a high risk of bloodborne infection. The 2-way group had similar rates of total and intravenous-related needlestick injuries compared to control groups. The PBC group had lower rates of total and intravenous-related needlestick injuries per 1,000 patient-days (rate ratios [RR], 0.32 and 0.24; 95°% confidence intervals [CI95], 0.12-0.81 and 0.09-0.61; P=.02 and P=.003, respectively) and per 1,000 productive hours worked (RR, 0.11 and 0.08; CI95, 0.01-0.92 and 0.010.69; P=.03 and P=.005, respectively) compared to controls.
Needlestick injuries continued in study areas despite the introduction of needleless devices, and risks of bloodborne pathogen transmission were similar to control areas. The PBC device group noted lower rates of needlestick injuries compared to controls, but there were problems with product acceptance, correct product use, and continued traditional device use in study areas. Low needlestick injury rates make interpretations difficult. Further studies of safety devices are needed and should attempt greater control of worker behavior to aid interpretation.