The Effect of Improving Basic Preventive Measures in the Perioperative Arena on <i>Staphylococcus aureus</i> Transmission and Surgical Site Infections
Authors: Randy W. Loftus, Franklin Dexter, Michael J. Goodheart, Megan McDonald, John Keech, Nicolas Noiseux, Andrew Pugely, William Sharp, Mel Sharafuddin, W. Thomas Lawrence, Mark Fisher, Patrick McGonagill, Jennifer Shanklin, Dionne Skeete, Chad Tracy, Bradley Erickson, Thomas Granchi, Lance Evans, Eli Schmidt, Joshua Godding, Raven Brenneke, Deanna Persons, Alexia Herber, Mark Yeager, Brent Hadder, Jeremiah R. Brown
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. <h3>Objective</h3> To assess whether improved basic preventive measures can reduce perioperative<i>Staphylococcus aureus</i>transmission and surgical site infections. <h3>Design, Setting, and Participants</h3> This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. <h3>Interventions</h3> Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. <h3>Main Outcomes and Measures</h3> Perioperative<i>S aureus</i>transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). <h3>Results</h3> Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative<i>S aureus</i>isolates (1.25 [2.11] vs 0.47 [1.13];<i>P</i> = .002). Treatment reduced the incidence of<i>S aureus</i>transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86;<i>P</i> = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76;<i>P</i> &lt; .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86;<i>P</i> = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92;<i>P</i> = .04; with clustering by surgeon: 95% CI, 0.03-0.51;<i>P</i> = .004). <h3>Conclusions and Relevance</h3> Improved basic preventive measures in the perioperative arena can reduce<i>S aureus</i>transmission and surgical site infections. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT03638947