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ACP HospitalistWeekly 1-13-10

Highlights

• Rapid screening, decolonizing can reduce surgical-site infections from S. aureus
• Chlorhexidine-alcohol superior to povidone-iodine for surgical-site antisepsis

Guidelines

• Updated guidelines on complicated intra-abdominal infections

Cardiology

• AHA updates recommendations on cardiovascular IED infections

FDA update

• Catheter recalled for potential to crack

Cartoon caption contest

• Put words in our mouth

Physician editor: A. Scott Keller, FACP

Editorial note: ACP HospitalistWeekly will not be published next week due to the Martin Luther King Jr. holiday.

Highlights

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Rapid screening, decolonizing can reduce surgical-site infections from S. aureus

Hospitals can lower the number of surgical-site infections acquired in their facilities by rapidly screening and decolonizing nasal carriers of non-methicillin-resistant Staphylococcus aureus at admission, a new study found.

In a randomized, double-blind, placebo-controlled trial, researchers screened 6,771 Dutch patients upon admission to one of five hospitals from October 2005 through June 2007. Of the 917 patients with positive nasal swabs for S. aureus who were enrolled in the intention-to-treat analysis, 808 had a surgical procedure done. Five hundred and four patients were decolonized with mupirocin nasal ointment and chlorhexidine gluconate soap, and 413 patients were given placebo. The study was published in the Jan. 7 New England Journal of Medicine.

In the mupirocin-chlorhexidine group, the rate of S. aureus infection was 3.4%, compared with 7.7% in the placebo group (relative risk, 0.42; 95% CI, 0.23 to 0.75). Mupirocin-chlorhexidine appeared most effective for deep surgical-site infections, with 0.9% of patients infected in the treatment group versus 4.4% in the placebo group (RR, 0.21; 95% CI, 0.07 to 0.62). All-cause, in-hospital mortality didn't differ between the two groups, but time to onset of nosocomial infection was shorter in the placebo group (P=0.005). Mean duration of hospitalization was also significantly shorter in the treatment group (crude estimate, 12.2 vs. 14.0 days; P=0.04). The number of S. aureus carriers who would need to be screened to prevent one hospital-acquired S. aureus infection was 250; the number needed to treat was 23.

The study results indicate that S. aureus decolonization has a preventive effect, reducing the risk of hospital-associated S. aureus infection by nearly 60%, the authors said. An important aspect of the study was use of real-time polymerase chain reaction assay to detect nasal carriage of S. aureus, which allowed targeted treatment to start within 24 hours—i.e., before patients were exposed to risk factors for hospital-acquired S. aureus, they noted. Also important was the decontamination of skin as well as nasal passages, and continuation of treatment for five days, even when surgery was done during the course of treatment, they said. Treatment was repeated three and six weeks after admission for patients still in the hospital, they said.

S. aureus is responsible for a minority (approximately 20% to 30%) of surgical-site infections, albeit an important subgroup of them, an editorialist noted.

The study results suggest using prophylaxis for S. aureus carriers who will undergo surgical procedures associated with a high risk of harmful outcomes if an infection develops at the site—i.e., open-heart surgery, or any procedure in which a foreign body is placed, he said. Immunosuppressed patients should also use prophylaxis, the editorialist said.

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Chlorhexidine-alcohol superior to povidone-iodine for surgical-site antisepsis

Cleaning patients' skin with chlorhexidine-alcohol before surgery is about 41% more protective against surgical-site infection than using povidone-iodine, a study found.

In a prospective, randomized trial, researchers assigned patients undergoing clean-contaminated surgery at one of six hospitals to preoperative chlorhexidine-alcohol skin scrub (409 patients), or povidone-iodine scrub and paint (440 patients). The former had their skin scrubbed with an applicator containing 2% chlorhexidine gluconate and 70% isopropyl alcohol, and the latter were scrubbed and painted with an aqueous solution of 10% povidone-iodine. The trial, published in the Jan. 7 New England Journal of Medicine, was conducted between April 2004 and May 2008.

The chlorhexidine-alcohol group had a surgical-site infection rate of 9.5%; the rate for the povidone-iodine group was 16.1%, a significant difference (relative risk, 0.59; 95% confidence interval, 0.41 to 0.85; P=0.004). The former was more protective against superficial incisional infections (4.2% vs. 8.6%, RR, 0.48; 95% CI, 0.28 to 0.84; P=0.008) and deep incisional infections (1% vs. 3%, RR, 0.33; 95% CI, 0.11 to 1.01; P=0.05), though not organ-space infections (4.4% vs. 4.5%) or sepsis from surgical-site infection. Kaplan-Meier estimates also showed a significantly longer time to infection after surgery in the chlorhexidine-alcohol group (P=0.004).

The superior protection of chlorhexidine-alcohol is due mostly to its efficacy in reducing rates of superficial and deep incisional infections caused mainly by gram-positive skin flora, the authors said. Two-thirds of surgical-site infections are confined to the incision, they added, so "optimizing skin antisepsis before surgery could result in significant clinical benefit." An editorialist agreed, saying the accumulated evidence from this and other studies suggests chlorhexidine-alcohol should replace povidone-iodine as the standard for preoperative surgical scrubs.

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Guidelines

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Updated guidelines on complicated intra-abdominal infections

The Surgical Infection Society and the Infectious Diseases Society of America released updated guidelines on the diagnosis and management of complicated intra-abdominal infection in adults and children last week, including a new section on appendicitis.

The guidelines, which were published in the Jan. 15 Clinical Infectious Diseases, replace those published in 2002 and 2003, and are meant for treating patients who either have complicated intra-abdominal infections or may be at risk for them. The new guidelines incorporate information from publications from 2003-2008. The recommendations include the following:

• Routine history, physical exam and lab studies will identify most patients with suspected intra-abdominal infection for whom further evaluation/management is warranted. For adults not undergoing immediate laparotomy, CT scan is the imaging modality of choice to find the presence and source of intra-abdominal infection.
• Antimicrobial therapy should be started once a patient gets a diagnosis of intra-abdominal infection, or when the infection seems likely. Antibiotics should be given as soon as possible for patients with septic shock. Patients without septic shock should start antimicrobial therapy in the emergency department.
• Antimicrobial therapy of established infection should be limited to 4 to 7 days, unless it is difficult to achieve adequate source control; longer durations haven't been associated with improved outcomes. Patients with persistent or recurrent clinical evidence of infection after 4 to 7 days should undergo diagnostic intervention, including CT or ultrasound imaging, and should continue treatment with effective antibiotic(s).
• Though no clinical findings for appendicitis are unequivocal, a group of findings that include characteristic abdominal pain, localized abdominal tenderness and laboratory evidence of acute inflammation will generally identify most patients with suspected appendicitis.
• Helical CT of the abdomen and pelvis with intravenous, but not oral or rectal, contrast is the recommended imaging procedure for patients with suspected appendicitis.

The full text of the guidelines is available online.

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Cardiology

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AHA updates recommendations on cardiovascular IED infections

The American Heart Association has issued updated recommendations on caring for patients with suspected or established cardiovascular implantable electronic device (CIED) infections.

In 2003, the AHA published recommendations on nonvalvular cardiovascular device infections. Since then, many research advances have been made centering on CIED infections. This led the AHA to issue an updated scientific statement on the diagnosis of these infections and their management. The statement was published online Jan. 4 by Circulation.

The scientific statement includes the following recommendations:

• All patients should have at least two sets of blood cultures drawn at the initial evaluation before prompt initiation of antimicrobial therapy for CIED infection.
• Duration of antimicrobial therapy should be 10 to 14 days after CIED removal for pocket-site infection and at least 14 days after CIED removal for bloodstream infection.
• All patients with definite CIED infection, as evidenced by valvular and/or lead endocarditis or sepsis, should have their devices and leads removed completely.
• Long-term suppressive therapy should be considered for patients who have CIED infection and are not candidates for complete device removal.
• Prophylaxis with an antibiotic that has in vitro activity against staphylococci should be administered. If cefazolin is selected, then it should be administered intravenously within 1 hour before incision; if vancomycin is given, then it should be administered intravenously within 2 hours before incision.

The full scientific statement is available online.

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FDA update

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Catheter recalled for potential to crack

A class I recall has been issued for the Trailblazer Support Catheter, the FDA and manufacturer ev3 Endovascular, Inc announced last week.

The device may crack near the radiopaque marker band. This may result in serious patient injury, including insufficient oxygen supply to the tissues, damage to blood vessels, heart attack, limb amputation, unplanned surgery, and/or death, the FDA said.

Affected devices were manufactured from Sept. 11, 2009 through Sept. 29, 2009 and distributed from Sept. 21, 2009 through Oct. 27, 2009. A full list of recalled model and lot numbers is online.

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Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E-mail all entries to acphospitalist@acponline.org. ACP staff will choose three finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated