Monday, 30 September 2013

Can we decrease Gram positive surgical site infections ?

Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis . BMJ 2013;346:f2743 doi: 10.1136/bmj.f2743 (Published 13 June 2013)
This is a systematic review and meta-analysis assessing the effectiveness of a bundle of nasal decolonisation and glyopeptide prophylaxis in preventing surgical site infections (SSI) in adults undergoing cardiac and orthopaedic surgery (predominantly joint replacement). This is an important area to study, as surgical site infections (SSI) significantly increase hospital length of stay, mortality and costs.

This MA looked at 39 trials (RCTs, quasi-RCTs, and retrospective cohort studies) in which a bundled intervention was employed, or one of the two strategies was used alone.
They found that nasal decolonization alone decreased the rates of S aureus SSIs (RR 0.41, 0.3 – 0.55), but there was high heterogeneity. When looking at RCTs alone this was not significant (0.63, 0.36 – 1.13).
 Glycopeptide prophylaxis protected against MRSA SSI (0.4, 0.2 – 0.8), but not all Gram positive bacteria (0.7, 0.47 – 1.04).
 Bundle intervention including both approaches found a significant reduction in the risk of SSI caused by all gram positive bacteria (0.41, 0.3 – 0.56). Importantly however, none of these were RCTs.
 So, this MA suggests the use of nasal decolonization in conjunction with glycoprotein prophylaxis may help reduce the incidence of S aureus SSI. However, there are significant limitations with this MA, particularly the poor quality of the studies included. Whilst attempts were made to mitigate this issue, there remains the need for a well conducted, adequately powered RCT in this area.
CF

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