Low Adherence to Outpatient Preoperative Methicillin-Resistant Staphylococcus aureus Decolonization Therapy

Abstract

In 2006, the Providence Veterans Affairs Medical Center in Rhode Island, USA implemented a preoperative methicillin-resistant Staphylococcus aureus (MRSA) colonization surveillance and decolonization programme. MRSA nares screening was conducted during surgical scheduling appointments from January 2006 to December 2009. Patients were provided 15 minutes of nursing education on MRSA, what to anticipate if MRSA-positive, appropriate decolonization therapy application techniques, and date-specific time lines featuring day-by-day instructions for use prior to surgery. The decolonization regimen was prescribed as follows: mupirocin 2% ointment to both nares twice daily for 5 days prior to surgery and use of hexachlorophene 3% or chlorhexidine gluconate 4% body wash once daily for 3 days prior to surgery. On the day of surgery, patients were rescreened and administered adherence surveys by nursing to ascertain the number of days each therapy was applied. Of the 45 MRSA-colonized outpatients who received the preoperative decolonization kit, 62.2% applied mupirocin to their nares as instructed for 5 days prior to their scheduled surgery. Body wash was applied for 3 days by 46.7% of patients. Most patients were male (one female), with a mean age of 57 years (standard deviation, 19). Surgery types included various non-cardiothoracic surgeries, the majority of which were orthopaedic, vascular, urological, hernia repairs, or tumour resections. Complete adherence to the decolonization regimen was reported by 31.1% of patients. The most common patient-reported reason for incomplete adherence related to recall, as several patients could not remember whether and when they applied each topical therapy. Five (11.1%) patients developed a postoperative MRSA infection in the 30 days following surgery, and 17 (37.8%) patients were still colonized on the day of surgery. Colonization persistence and 30-day MRSA infections did not vary significantly by proportion of days covered (PDC) (P 0.10 for all comparisons). Body wash PDC decreased significantly over the study period (P<0.03). No temporal trends were observed in mupirocin PDC, adherence to both mupirocin and body wash, colonization persistence, or MRSA infections. It is concluded that despite comprehensive education, patient-reported adherence to preoperative MRSA decolonization therapy was low (31.1%) in the outpatient setting.