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In the absence of established methicillin-resistant Staphylococcus aureus (MRSA) screening programs, many centers use a history of a positive culture or a nasal screen as a surrogate for preoperative MRSA colonization status. We aimed to evaluate the test characteristics of these surrogates.
Retrospective cohort study.
Veterans Affairs Boston Healthcare System surgical patients with a preoperative nasal MRSA polymerase chain reaction (PCR) screen.
We assessed the performance of a history of a MRSA-positive culture or a positive nasal MRSA PCR screen during the year prior to surgery for predicting the preoperative nasal PCR screen result. The associations between MRSA history and postoperative outcomes, including MRSA cultures and infections, were also evaluated.
Among 4,238 patients, a positive MRSA culture history had a sensitivity of 19.7% (95% confidence interval [CI], 15.4%–24.8%) and positive predictive value of 57.3% for the preoperative nasal MRSA status. The specificity of MRSA culture history was 99% (95% CI, 98.5%–99.2%). Prior-year nasal MRSA screen results had similar test characteristics. A history of a MRSA-positive culture was associated with an increased risk of postoperative MRSA-positive cultures (risk ratio [RR], 3.54 [95% CI, 1.70–7.37], P< .001) but not of infections (RR, 1.71 [95% CI, 0.58–5.01]), after adjustment for preoperative nasal MRSA status, vancomycin surgical prophylaxis, surgical scrub, and age.
A history of a MRSA-positive culture and a positive nasal PCR screen are poor surrogate markers of preoperative colonization status, missing at least 70% of MRSA-colonized patients. Prior-year history is also not independently associated with MRSA-related postoperative infections. Strong consideration should be given to preoperative MRSA screening in patients at high risk for surgical complications.
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.
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