Staphylococcus Aureus and the Perioperative Patient
Staphylococcus aureus is the most common pathogen associated with surgical site infections (SSIs; Safer Healthcare Now!, 2014; Spencer & Edmiston, 2014; Tong, Davis, Elchenberger, Holland, & Fowler, 2015). Tong et al. (2015) state that “approximately 30% of the human population is colonized with S. aureus” (p. 605). This colonization frequently occurs in the nares and skin (Safer Healthcare Now!, 2014). Most S. aureus SSIs are endogenous, “brought into the hospital environment by patients themselves”(Spencer & Edmiston, 2014, p. 604). This paper will discuss how S. aureus is transmitted to the patient and the challenges associated with eliminating S. aureus from the surgical environment, potential complications that may occur as a result of S. aureus SSI, as well as perioperative precautions specific to S. aureus.
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The act of making a surgical incision into the skin violates the human body’s first line of defense against pathogens (King & Spry, 2015). The incision site acts as a portal of entry for microorganisms, particularly those present in the skin flora. Therefore, S. aureus has the potential to complicate every surgical procedure (Fry, 2013). While efforts are made to eliminate the presence of S. aureus from the skin on both scrubbed operating room (OR) personnel through surgical hand scrubs, and the patient through antimicrobial skin prepping, it is impossible to sterilize the skin. King and Spry (2015) explain that “this is because up to 20% of patient’s skin resident microorganisms reside in the hair follicles and sebaceous glands” (p. 57). Antiseptic skin preparations have no bactericidal effect below the level of the epidermis, therefore they can only reduce the microbial load, not eliminate it (King & Spry, 2015). Consequently, all surgical incisions must be considered contaminated to some extent (Edmiston & Spencer, 2014).
S. aureus has developed several mechanisms that allow it to evade the human immune cell response, “including blocking chemotaxis of leukocytes, sequestering host antibodies, hiding from detection via polysaccharide capsule or biofilm formation, and resisting destruction after ingestion by phagocytes” (Tong et al., 2015, pp. 612-613). S. aureus continues to develop resistance to antibiotics demonstrating the bacterium’s high adaptability (Fry, 2013). This antibiotic resistance has led to the development of antibiotic resistant strains of S. aureus, most notably including methicillin-resistant S. aureus (MRSA). King & Spry (2015) acknowledge that while the incidence of MRSA-SSI is only 1%, MRSA-SSI frequently results in particularly poor and potentially fatal outcomes for patients, making MRSA a topic of particular interest when discussing S. aureus SSIs.
The most common complication associated with S. aureus SSIs is skin and soft tissue infections (Fry, 2013). The severity of these skin and soft tissue infections can vary, from impetigo to necrotizing fasciitis (Tong et al., 2015). Other potential diseases are frequently related to the site and type of surgery performed. For example, S. aureus SSI infection after orthopedic surgeries may result in osteomyelitis or septic arthritis (Tong et al., 2015). Other surgical complications of infection include bacteremia, infective endocarditis, pleuropulmonary infections, toxic shock syndrome, epidural abscess, meningitis, urinary tract infections, and septic thrombophlebitis (Tong et al., 2015). Complications can also arise with any implanted devices, including prosthetic joints, cardiac devices, prosthetic heart valves, intravascular catheters, ventricular shunts, and breast implants (Tong et al., 2015). Complications of S. aureus infection often require some form of surgical intervention, including surgical debridement and removal of implants and devices if present (Tong et al., 2015). Tong et al. (2015) explain why surgical interventions are often necessary with S. aureus SSIs associated with implanted devices: “S. aureus forms a biofilm on the surface of a foreign device…The biofilm provides a protective matrix around the encased bacteria and is highly resistant to host immune defenses and antimicrobials” (pp. 266-267?). If a patient is not a candidate for surgical intervention, aggressive intravenous antibiotic therapy is initiated (Tong et al., 2015).
A bundled approach to reduce the risk of S. aureus SSI includes preoperative active surveillance, decolonization with nasal mupirocin ointment, and cleansing with chlorhexidine gluconate (CHG; Edmiston & Spencer, 2014; Fry, 2013). Active surveillance involves swabbing patients’ nares to identify those who are colonized with S. aureus or MRSA (Zinn, 2013).Nasal mupirocin ointment is currently the most effective treatment for eradicating S. aureus colonization of the nares (Edmiston & Spencer, 2014; Fry, 2013; Safer Healthcare Now!, 2014). However, Edmiston and Spencer (2014) recommend only using mupirocin ointment in targeted patient populations undergoing high-risk surgical procedures (i.e. cardiothoracic procedures and procedures that involve implanted devices) to avoid development of mupirocin resistance. When S. aureus is isolated in a patient’s nares, they should wear a mask to protect the incision site from contamination from the nose (Operating Room Nurses Association of Canada [ORNAC], 2017).
Cefazolin is the recommended systemic prophylactic antibiotic for covering S. aureus and other skin flora in clean surgical procedures (Fry, 2013). In addition to cefazolin, vancomycin should also be used for patients who have screened positive for MRSA who will be undergoing high-risk surgical procedures (Safer Healthcare Now!, 2014). Vancomycin should not be used prophylactically in patients who do not have confirmed MRSA as this can place the patient at greater risk for a methicillin-sensitive S. aureus SSI (Fry, 2013; King & Spry, 2015; Safer Healthcare Now!, 2014).
Hand hygiene must be enforced among all OR personnel (ORNAC, 2017). Ensuring easy access to alcohol-based hand rub will enhance hand hygiene compliance among non-scrubbed personnel (Edmiston & Spencer, 2014). Artificial nails should be banned as they are “known to promote the growth of S. aureus” (ORNAC, 2017, p. 145). In patients with known MRSA colonization, contact precautions must be initiated in addition to routine practices (King & Spry, 2015; ORNAC, date). Contact precautions include segregating the patient, wearing a gown and gloves when there is potential for contact with contaminated fluids or materials, limiting patient transportation to essential movement only, and cleaning and disinfecting patient care equipment as close as possible to the time of use (King & Spry, 2015).
UV technology is gradually being introduced into hospitals because it has the ability to “deactivate DNA in bacteria, dust mites, viruses, and other pathogens” (Spencer & Edmiston, 2014, p. 606). UV technology has shown to be effective in eradicating MRSA in the environment (Spencer & Edmiston, 2014). Spencer and Edmiston (2014) emphasize the importance of the role of the RN circulator in ensuring environmental safety to prevent SSIs: “RN circulators ensure that room turnover is performed properly and terminal cleaning is performed on a daily basis” (p. 607).
Reducing skin shedding in the OR environment is important among OR personnel as employees may be carriers of S. aureus themselves among their own skin flora. ORNAC (2017) recommends wearing appropriately sized hospital-laundered scrub attire, including a long sleeve jacket if non-scrubbed in the OR. The Association of perioperative Nurses (AORN) advises against wearing skull caps in the OR as these do not adequately cover the nape of the neck (Edmiston & Spencer, 2014). This is because “case reports have shown cross infection from contaminated scalp squames and hair in the OR and the development of SSIs” (Edmiston & Spencer, 2014, p. 592). Bouffant hair covers should be used instead as they effectively cover all hair and ears (ORNAC, 2017). Limiting traffic, keeping doors closed, and the number of personnel in the OR will reduce turbulent air flow, which has the potential to spread microorganisms into the sterile field (ORNAC, 2017). Non-scrubbed OR personnel should never lean over a sterile field for risk of skin shedding contaminating the sterile field (ORNAC, 2017). Enforcing a patient and visitor dress code in the semirestricted and restricted areas of the surgical suite will reduce also the number of microorganisms brought into the surgical environment (ORNAC, 2017). All members of the OR team must be compliant with these measures to ensure appropriate infection control is maintained and a safe environment for the patient is maintained (Spencer & Edmiston, 2014).
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Due to the presence of S. aureus among the skin flora of a large percentage of patients, S. aureus has the potential to cause SSI in many patients undergoing any type of surgical procedure. S. aureus is a highly adaptive microorganism that has developed several mechanisms that aide in its ability to evade the human body’s immune system and many antibiotics on the market today. Complications associated with S. aureus SSI often have negative outcomes requiring surgical intervention or intensive antibiotic therapy. Fry (2013) states that “intelligent use of antimicrobials for preventive and treatment strategies and rigorous infection control practices remain the methods to achieve the best outcomes for the surgical patient in combating S. aureus” (p. 8). These practices include screening and decolonization procedures for patients with S. aureus isolated in the nares, appropriate use of clindamycin and vancomycin as preoperative prophylactic antibiotics, environmental cleaning strategies, rigorous use of hand hygiene and precautions in the OR, and strategies to reduce skin shedding in the OR. Ultimately, teamwork is essential to creating a safer environment for patients and reducing the number of S. aureus SSIs (Spencer & Edmiston, 2014).
- Edmiston, C. E., & Spencer, M. (2014). Patient care interventions to help reduce the risk of surgical site infections. AORN Journal, 100(6), 590-602. doi:10.1016/l.aorn.2014.10.008
- Fry, D. (2013). The continued challenge of Staphylococcus aureus in the surgical patient. The American Surgeon, 79(1), 1-10. Retrieved from https://sesc.org/american-surgeon-journal
- King, C. A., & Spry, C. (2015). Infection prevention and control. In J. C. Rothrock (Ed.), Alexander’s care of the patient in surgery (15th ed., pp. 54-106). St. Louis, Missouri: Elsevier Mosby.
- Operating Room Nurses Association of Canada (ORNAC). (2017). The ORNAC standards, guidelines, and position statements for perioperative registered nurses (13th ed.). Canada: Author.
- Rothrock, J. (2015). Alexander’s care of the patient in surgery (15th ed.). St. Louis, Missouri: Elsevier Mosby.
- Safer Healthcare Now! (2014). Prevent surgical site infections: Getting started kit [PDF file]. Retrieved from https://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Surgical%20Site%20Infection/SSI%20Getting%20Started%20Kit.pdf
- Spencer, M., & Edmiston, C. E. (2014). The role of the OR environment in preventing surgical site infections. AORN Journal, 100(6), 603-608. doi:10.1016/l.aorn.2014.10.009
- Tong, S. Y. C., Davis, J. S., Elchenberger, E., Holland, T. L., & Fowler, V. G., Jr. (2015). Staphylococcus aureus infections: Epidemiology, pathophysiology, clinical manifestations, and management. Clinical Microbiology Reviews, 28(5), 603-661. doi:10.1128/CMR.00134-14
- Zinn, J. (2013). Surgical patients: A vulnerable population. AORN Journal, 98(6), 647-652. doi:10.1016/j.aorn.2013.09.004
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