JOURNAL READING

Post-operative MRSA infections

in head and neck surgery
ABSTRACT
 ABSTRACT
Purpose

Serious
Investigates
SSI & MRSA incidence and risk for MRSA
post-
operative
SSIs at tertiary medical institution
complication

Head and
Worse
neck cancer
outcomes
patient
 ABSTRACT
Material and methods

SPSS 
identify
trends
2008-2013
21 variables
(tumor characteristics,
Multivariative analysis
577 head and patients(age,
controlled demographic,
BMI, ASA
class,operative
length ofcourse,
stay) was
neck procedure cultures)
completed
 ABSTRACT
Results 24 (21%) • Hospital exposure within the preceding year
MRSA was a significant risk factor for MRSA SSI
development (OR 2.665, 95% CI: 1.06–
6.69, z statistic 2.086, p = 0.0369)
113 SSIs • Immunosuppressed patients were more
prone to MRSA infec-tions (OR 14.1250,
577 95%CI: 3.8133–52.3217, p b 0.001)
procedures• Patients with a history of chemotherapy (OR
3.0268, 95% CI: 1.1750–7.7968, p =
0.0218)
• MRSA SSI resulted in extended post-
operative hospital stays (20.8 ± 4.72 days, p
= 0.031).
 ABSTRACT
Conclusion
history of chemotherapy,
immunosuppression, or
recent hospital exposure
prior to their surgery

• Higher risk of developing MRSA-specific SSI

• May benefit from prophylactic anti-biotic therapy
with appropriate coverage
• Patients who develop MRSA SSIs are likely to have
an ex-tended postoperative inpatient stay
INTRODUCTION
 INTRODUCTION

• an infection occurring at or adjacent to the incision

MRSA
within thirty days of the proce-dure, or within ninety
SSIs days if a prosthetic was implanted
2–5% of surgical
Resistance to many first line
antibin 2–5% of surgical patients
in the United States, resulting in a
total of 300,000–500,000 cases of
patients  300,000–
SSIs per yeariotics
500,000 cases
per year

>> length of stay, mortality,

charges
 INTRODUCTION
skin subsequent
breakdown, increased
cellulitis, length of stay,
fistula
why MRSA is often themortality,
identified
formatio hospital costs
pathogen in these patients?

Head• and
theneck
surgical
cancer site
• The operating sites of these patients, the nares and
• the
• cheeks
these greater
patients usehave
often of antibiotics
weakened in
hostthis subset
defenses
 colonization
complicated
of their
due to patients.
malignancy and/or chemoradiation
• greater exposure to hospital
antibiotics  recur-rent head
• and
longer
MRSA
neck operating
infectionstimes
has been and prolonged
implicated
course
(i.e. tonsillitis,inotitis
head post-operative
and neck
media, and
hospital or
sinusitis) care  acquiring
post-operative
peri-operative nosocomial
infec-tions
antibiotic useMRSA
worldwide
in clean-
• contaminated
require flap reconstruction
procedures
 INTRODUCTION
Purpose of this study

create a foundation for

future studies 
important to elucidate the
The complications of post-operative prevention and treatment
risk factors and
MRSA infections can be severe of post-operative MRSA
complications
infections in
otolaryngology
MATERIALS AND METHODS
 MATERIALS AND METHODS

Eligible patients  Compiled into a

Retrospective underwent major
cross-referencing lists
head and/or neck
generated from the comprehensive,
chart review N18 years of age surgery at UH-CMC by
hospital's infection
the Head and Neck
control and coding de-identified
study Surgery Department
departments
patient list

attending physicians documented surgical

Approval from UH-
Specific inclusion between January 1, site infection during
CMC Institutional
criteria 2008 and January 1, their post-operative
Review Board
2014 hospitalization
 MATERIALS AND METHODS

Surgical site infections were defined as infections occurring within 30

days of the procedure in accordance with CDC parameters

Patients with multiple SSIs follow-ing separate surgeriesonly the

first incidence of SSI was included

SSIs were determined by the history and physical exam findings (i.e.:
ery-thema, edema, purulence)

Two groups were established comparing the qualities of patients

with MRSA infections to those with non-MRSA infections
 MATERIALS AND METHODS

Independent
variables

Student'sSPSS
t-test
Continuous Ms Excel
Data
variables
Pearson’
or theStatistics
Mann-22
Whitney test
s X2 test
Dependent
variables
RESULTS
 RESULTS
Variable MRSA Non-MRSA p Value
Demographics Mean age (years) 62.2 59.2 0.140
Gender (% female) 50% 45.6% 0.985
Smoking status (%) 83.3 71.1 0.692
Alcohol use (%) 41.6 27.8 0.633
Illicit drug use (%) 25% 12.2% 0.487
Hypertension 54.2 57.3 0.995
BMI 24.0 25.6 0.140
Diabetes mellitus 33.3 18.9 0.511
HbA1Ca 6.6 7.5 0.124
a. In patients with diagnosed Vascular disease 45.8 26.7 0.352
Prealbumin (mg/dL) 20.5 22.7 0.198
diabetes mellitus, n = 20.
Albumin (g/dL) 3.4 3.7 0.039
b. In patients requiring revision Prior inpatient stay (days) 4 3.53 0.037
surgery due to infection, n = 40. Immunosuppression 33.3% 14.2% 0.202
c. In patients requiring readmission Prior head/neck radiation 45.8 47.7 0.925
due to infection, n = 72. Prior chemotherapy 37.5 34.4 0.781
Prior head/neck surgery 33.3% 28.9% 0.673
Postoperative hospital stay (days) 20.8 11.3 0.031
Estimated blood loss (cc) 216.14 238.7 0.329
Procedure duration (min) 575.5 463.5 0.049
Interim before SSI identified (days) 20.0 18.8 0.436
Interim before return to ORb 35.8 19.8 0.165
Number of operative revisionsb 0.7 0.5 0.214
Interim until readmission (days)c 37.3 21.1 0.148
Length of readmissionc 6.8 5.9 0.226
 RESULTS
Patient population Bacteria Positive Culture (n) Percentage (%)

MRSA 24 21.23

MSSA 21 18.58
577 procedures
Pseudomonas aeruginosa 27 23.89

MRSA and P. aeruginosa 2 1.76

MSSA and P. aeruginosa 4 3.53

113 SSIs
Gram-positives ± MRSA 33 29.20

Gram-negatives ± MRSA 37 32.74

Streptococci 15 13.27

Fungal 14 12.38
24 (21%) MRSA 2 1.76
Yeast
Candida spp. 12 10.61

Mixed 12 10.61
 RESULTS
Patients population
• Majority of SSIs occurred following free-flap reconstruc-tion (n = 71,
62.83%)  free flaps, total and partial resections of the larynx, pharynx,
mandible, maxilla, tongue, thyroid and parathyroid glands, salivary
glands, and reconstruction procedures
• All patients received perioperative antibiotics in accordance with
institution policy, with dosing individualized to the patient
• Most common antibiotic regimens  clindamycin (600 mg/8 h 4 days)
and ampicillin-sulbactam (3 g/6 h 4 days)
 RESULTS
Prior hospitalization
• Prior inpatient stay  significant risk factor (OR 2.665, 95% CI:
1.06–6.69, p = 0.0369)
• Post-operative MRSA infection (7.33 ± 2.03 days) & non-MRSA
infections (2.3 ± 0.50 days)   >> time in the hospital
 RESULTS
Prior head and neck treatments
• Prior head and neck radiation did not significantly increase risk for MRSA
infection over any other type of infection (OR 0.9249, 95% CI: 0.3748–
2.2822, p = 0.8654)
• Neither did prior chemotherapy (OR 1.142, 95% CI: 0.4488–2.9053, p =
0.7806)
• A history of head and neck surgery was also found to not affect risk of
developing MRSA infection (OR 1.2308, 95% CI: 0.4697–3.2252, p =
0.6727)
• Prior chemo-therapy did increase risk for developing MRSA infection over
no infetion (OR 3.0268, 95% CI: 1.1750–7.7968, p = 0.0218), although this
increase in risk was not demonstrated by prior radiation or prior surgery.
 RESULTS
Postoperative hospital stay
(p = 0.031)
MRSA SSIs
patients
(20.8 ± 4.72 days)

patients non-MRSA SSIs

(11.3 ± 0.98 days)
 RESULTS
Return to OR and readmission
MRSA SSIs 10 required 89 non-MRSA
return trips to the OR SSIs
(41.7%)

35 required
returns to the
OR (39.3%)

4 required multiple trips

(16.7%)
5 required
multiple trips
(0.56%)
 RESULTS
Return to OR and readmission
• In patients with MRSA SSI  15 patients required readmission
for manage-ment of infection (62.5%)
• In non-MRSA SSI  57 patients required readmission (64%)
• No statistically significant difference
 RESULTS
Estimated blood lost
• There was no statistical difference between average blood losses in patients
who developed MRSA SSIs compared to non-MRSA SSIs
• An increase in estimated blood loss (EBL) was shown to be a significant risk
factor for SSI with P. aeruginosa; infected patients lost on average twice as
much blood (400 cm3) during their procedures compared to patients who
acquired other SSIs (200 cm3)
• (p b 0.001).
DISCUSSION
 DISCUSSION

significant
comorbidity
MRSA SSI and increased
hospital
charges

serious post-
operative
complication
 DISCUSSION
Risk factors for MRSA SSI in head and neck cancer
surgery

• Pre-operative hospital stay • Smoking

• Post-operative hospital stay • Alcohol abuse
• Increased length of procedure • Poor dentition
• Use of broad-spectrum antibiotics • Concurrent chronic disease
• Age N 65 • Malnutrition
 DISCUSSION
Complications of MRSA SSI in head and neck
surgery
• Prolonged post operative hospital stay
• Increased financial burden
• Fistula formation
• Cellulitis
• Scarring
 DISCUSSION
• The results of our study are limited due to the selected population and the
intrinsic limitation of using a retrospective approach
• The list of patients gathered for this study included patients who had a SSI
while admitted to our institution, and does not include patients who had
outpatient management of surgical site infections, or SSIs treated at a different
institution
• More minor infections may also be underreported
 DISCUSSION
• The studied population posed greatest interest to us due to the increased cost
of treatment and increased prevalence of significant comorbidities of patients
treated in the inpatient setting
• It would be helpful to know which patients were known to be MRSA colonized
prior to surgery, and which patients received prophy-lactic antibiotics to prevent
MRSA infection
• Using a prospective study of a homogenous patient population at our institution
would negate some of these limitations, as well as including outpatient-treated
infections.
CONCLUSION
 CONCLUSION

• Increased hospital exposure prior to the procedure, a history of chemotherapy,

or immunosuppression  risk factors for development of MRSA SSI over an
SSI by other organisms
• These patients may benefit from preoperative screening for MRSA colonization
or targeted prophylactic antibiotic therapy to prevent this serious surgical
complication
• MRSA SSIs  longer length of post-operative hospital stay  >> cost and
patients risk for further infection and complications of immobilization as their
inpatient stay is prolonged
THANK YOU