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Staphylococcus aureus screening and decolonization reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery

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Summary

In a controlled before-and-after study in a single centre, it was aimed to determine whether identification of Staphylococcus aureus nasal carriers followed by nasal mupirocin ointment and chlorhexidine soap reduced surgical site infections (SSIs) among 182 patients undergoing deep brain stimulation. In all, 119 patients were included in the control group and 63 in the screening group. There was a significant SSI decrease from 10.9% to 1.6% between the two groups (P < 0.04; relative risk: 0.13; 95% confidence interval: 0.003–0.922). There were eight SSIs involving S. aureus in the control group, none in the screening group. No specific risk factors for SSI were identified.

Introduction

Deep brain stimulation (DBS) is a major surgical treatment in neurological diseases resistant to medical treatment such as Parkinson disease, essential tremor, primary dystonia, or Tourette syndrome.1 This procedure is safe, effective, and well tolerated by patients but surgical site infection (SSI) remains a major problem with rates up to 15%.2 The DBS system device includes intracranial electrodes, subcutaneous wire extensions, and internal pulse generators (IPGs).2, 3 When SSI occurs, partial or total removal of the system device is generally necessary, along with antibiotic therapy. However, superficial SSIs may sometimes be treated conservatively with antibiotics alone.

Staphylococcus aureus is the most frequent bacterium identified in SSIs after DBS procedures, accounting for 36–57% of infections; nasal carriage is known to be a direct risk factor for nosocomial S. aureus infections, including SSI.2, 3, 4 Three approaches for the eradication of S. aureus exist: preoperative systemic antibiotics, bacterial interference, and local application of antibiotics. In the latter case, mupirocin nasal ointment is widely used.4, 5 In 2010, a randomized, double-blind, placebo-controlled and multicentre trial showed that screening and decolonization of nasal carriers of S. aureus using nasal mupirocin and chlorhexidine soap reduced S. aureus nosocomial infection, especially deep SSI.6 To our knowledge, this method has never been studied among patients undergoing a DBS procedure.

The aim of our study was to assess the effectiveness of screening and decolonization of S. aureus on SSI rate in patients undergoing DBS implantation at our centre.

Section snippets

Study design

A controlled before-and-after study was used. From January 2008 to December 2012, we included in the control group 119 patients admitted for DBS procedure. From January 2013 through June 2015, screening for nasal carriage of S. aureus among 63 patients began at their preoperative consultation; these patients constituted the screening group. The primary outcome of the study was the occurrence of SSI in each group. Written informed consent was obtained from each participant and the study was

Results

There were significant differences between the two groups: one SSI occurred in the screening group (1.6%) due to Enterobacter aerogenes and 13 infections in the control group (10.9%) (relative risk: 0.13; 95% confidence interval: 0.003–0.922; P = 0.04) (Table I). SSIs in the control group were due to S. aureus in eight patients (61.5%); Escherichia coli, Micrococcus sp., and Propionibacterium acnes accounted for one case each, and in two cases no bacterium was identified.

The two patient groups

Discussion

This study showed that detection of S. aureus nasal carriage followed by decolonization with mupirocin nasal ointment and chlorhexidine gluconate soap significantly reduced the risk of SSI in DBS patients. In a study of 6771 patients in internal medicine, cardiothoracic, vascular, orthopaedic, gastrointestinal or general surgery departments, Bode et al. reduced the deep SSI rate of 79% using screening and decolonization of S. aureus nasal carrier admission during the week before admission.6 Our

Acknowledgement

We thank Mrs D. McKeown for assisting with language revision.

References (10)

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    In the intervention groups, one study reported three total infections, with one due to Staphylococcus epidermidis (S epidermis) and one due to Pseudomonas aeruginosa—the other culture grew no organisms.25 Enterobacter aerogenes (E aerogenes) was the cause of the single infection in one study.27 Two studies did not report infectious causes in the intervention group, and one study observed zero infections.28

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    Our results support previous reports that stimulation-sparing management of S aureus may be ineffective because six of eight cultures of patients requiring additional (partial) removal of the stimulation after IV antibiotics were positive for S aureus.29 S aureus screening and subsequent decolonization may therefore be considered, because it has been shown to reduce DBS-associated SSI incidence.30 Initial treatment with IV antibiotics of SSIs involving multiple sites failed.

  • Deep Brain Stimulation-Related Surgical Site Infections: A Systematic Review and Meta-Analysis

    2021, Neuromodulation
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    Particularly, two studies (42,73) examined the association between the risk of SSIs and the perioperative implementation of intra-wound vancomycin powder (dosage: 200–400 mg (42) and 1 g (73), respectively) in addition to systemic prophylactic antibiotic use yielding a statistically significant summary OR of 0.26 (95% CI: 0.09–0.74) without significant heterogeneity (I (2): 0.0%; Supporting Information Fig. 2a). The preoperative screening for Staphylococcus aureus nasal carriage and body decolonization was nonstatistically significantly associated with DBS-related SSI risk (summary OR: 0.16, 95% CI: 0.02–1.25, n = 2 studies; I2: 0.0%; Supporting Information Fig. 2b) (10,105). In the same context, two studies did not show any significant effect of nonshaving of cranial hair in DBS surgery compared to shaving (OR: 0.61, 95% CI: 0.07–5.59) (66), as well as of preoperative antiseptic wash compared to no wash (OR: 0.11, 95% CI: 0.006–1.90) (67) on the risk of SSIs (Supporting Information Table S4).

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