Surgical site infection prevention initiative patient attitude and compliance.
Abstract: Background. Although the effect of Staphylococcus aureus (SA) decolonization on surgical site infection (SSI) rates has been studied, patient tolerance and acceptance of these regimens has not been assessed. Surgical patients at our hospital's Pre-Admission Testing Clinic (PAT) receive SA reduction protocols instructing the preoperative use of chlorhexidine gluconate (CHG) soap and intranasal mupirocin ointment (MO). Certain insurers do not cover MO costs resulting in out of pocket (OOP) expenses for some patients.

Objective. This study assessed patient attitudes and compliance with our hospital's SA decolonization regimen.

Methods. One-hundred-forty-six patients received surveys. Descriptive statistics were used for analysis.

Results. Of respondents fitting inclusion criteria, 81% followed the MO protocol (MO users) while 89% followed the CHG protocol (CHG users). Fifty-four percent of MO users reported OOP expenses and 13% reported a hard or very hard financial burden. Ninety-three percent of CHG users reported the protocol was easy or very easy to follow.

Conclusion. Eighty-one percent of patients receiving the SA protocol were fully compliant despite cost or difficulty obtaining MO. Given these barriers and some difficulty with CHG application, we hypothesize compliance may be improved if MO is provided to patients without OOP expenses and if the CHG application method is simplified.
Article Type: Clinical report
Subject: Staphylococcus aureus infections (Prevention)
Staphylococcus aureus infections (Analysis)
Staphylococcus aureus infections (Health aspects)
Staphylococcus aureus infections (Surveys)
Staphylococcus aureus (Analysis)
Staphylococcus aureus (Health aspects)
Staphylococcus aureus (Surveys)
Surgery (Analysis)
Surgery (Health aspects)
Surgery (Surveys)
Antibacterial agents (Usage)
Antibacterial agents (Analysis)
Antibacterial agents (Health aspects)
Antibacterial agents (Surveys)
Patient compliance (Analysis)
Patient compliance (Health aspects)
Patient compliance (Surveys)
Staphylococcal infections (Prevention)
Staphylococcal infections (Analysis)
Staphylococcal infections (Health aspects)
Staphylococcal infections (Surveys)
Medical research (Analysis)
Medical research (Health aspects)
Medical research (Surveys)
Medicine, Experimental (Analysis)
Medicine, Experimental (Health aspects)
Medicine, Experimental (Surveys)
Infection (Prevention)
Infection (Analysis)
Infection (Health aspects)
Infection (Surveys)
Authors: Ramos, Nicholas
Skeete, Faith
Haas, Janet P.
Hutzler, Lorraine
Slover, James
Phillips, Michael
Bosco, Joseph
Pub Date: 10/01/2011
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: Oct, 2011 Source Volume: 69 Source Issue: 4
Product: Product Code: 8000410 Surgical Procedures; 2834880 Bacteriostats; 8000200 Medical Research; 9105220 Health Research Programs; 8000240 Epilepsy & Muscle Disease R&D NAICS Code: 62 Health Care and Social Assistance; 325412 Pharmaceutical Preparation Manufacturing; 54171 Research and Development in the Physical, Engineering, and Life Sciences; 92312 Administration of Public Health Programs SIC Code: 2834 Pharmaceutical preparations
Accession Number: 289120466
Full Text: Surgical site infections (SSIs) present a great challenge to health care facilities in the United States. Surgical site infections are associated with increased morbidity, mortality, and extensive resource utilization. (1-3) A variety of measures including prophylactic antimicrobial regimens and improved sterilization techniques have demonstrated effectiveness in reducing SSIs and the morbidity associated with them. (4)

The most common organism causing SSI in high risk orthopaedic patients is Staphylococcus aureus. Many studies have looked at the impact of active reduction of Staphylococcus aureus (SA) colonization prior to surgery on SSI. While SA is a common component of normal human flora, it has been established as a significant causative pathogen in SSIs. (2,5) Intranasal mupirocin treatment and preoperative use of antimicrobial soaps are two strategies that have demonstrated success in the reduction of SA colonization and SSIs. (3,6-8) However, patient tolerance and attitude toward these protocols has not been well investigated. Additionally, certain insurers do not cover prescriptions used in SA decolonization regimens causing some patients to incur significant out of pocket (OOP) expenses. The effectiveness of an eradication regimen is largely dependent on patient compliance and independent self-care. Measures should be taken to ensure successful patient completion of these regimens to optimize SSI risk reduction. An assessment of patient attitude and expense associated with SA reduction protocols would yield valuable insight toward improving design, patient compliance, and successful completion of SA decolonization regimens. Our study evaluated these parameters in a cohort of patients undergoing hip and knee replacement and spine surgery at the NYU Langone Hospital for Joint Diseases.


One-hundred-forty-six patients undergoing total joint arthroplasty or spine surgery at the NYU Langone Hospital for Joint Diseases were enrolled in the study. The SA eradication regimen was introduced to patients at our Pre-Admission Testing clinic (PAT). Patients were instructed to purchase a chlorhexidine gluconate (CHG) containing soap and were prescribed a 5-day course of intranasal mupirocin ointment (MO). Standardized protocols for both CHG and MO preoperative treatment and instructions on how to obtain the prescriptions were provided to patients in a one page handout. Nasal cultures were also performed preoperatively. On the day of surgery, hospital staff assessed patient compliance with the pre-operative SA reduction regimen and obtained culture results. Postoperatively, patients were given anonymous surveys assessing OOP expenses and attitudes toward the eradication regimen. The survey evaluated patient awareness and concern for infection, ease of compliance with standardized SA reduction protocols, and the financial burden of treatment. Compliance items were rated on a 4-point Likert type scale ranging from very easy to very hard. Completed surveys were collected prior to discharge. We analyzed the survey response data using standard statistical methods for determining averages and percentages.


Survey Distribution

A summary of survey results is provided in Table 1. Of the 146 surveys distributed, 100 (68%) were returned. The mean age of respondents was 55. Forty-eight respondents were male and 50 were female. Two did not specify gender.

PAT Attendance

Of the 100 patients who completed surveys, 85% attended PAT and received the CHG and MO protocol. Fourteen percent did not attend PAT, but received instructions from their surgeon's office, and 1% was unable to recall PAT attendance.

MO and CHG Compliance

Eighty-one percent of those who submitted survey responses indicated they had followed the MO protocol (MO users) while 89% indicated they followed the protocol for CHG (CHG users). Fifty-four percent of MO users reported an out of pocket expense ranging from $2 to $115 with a mean of $31. Thirteen percent of MO users indicated the expense was a hard or very hard financial burden. Six percent of MO users reported difficulty in locating the MO. Of CHG users, 93% reported CHG was easy or very easy to use. Only 46% of respondents indicated a concern with SSI.


Studies have shown that SA colonization is a significant risk factor for SSIs among surgical patients. (9,10) Kluytmans and colleagues (11) quantitatively demonstrated this risk, finding that SA carriers have a seven fold increased risk of post-surgical infection compared to non-carriers. Consequently, SA decolonization has been employed as a strategy for reducing SSI.

Several therapies have shown promise for preoperative SA decolonization. Staphylococcus aureus frequently colonizes the nares, making this anatomical site the focus of many eradication regimens. Various studies have demonstrated the success of intranasal mupirocin treatment in SA decolonization. (12,13) Chlorhexidine gluconate soap usage has also proven effective in reducing extranasal SA colonization. (14) While the effectiveness of these regimens in SA decolonization is widely corroborated, their effect on SSI risk reduction is still being debated. Numerous studies have demonstrated a reduction of SSI rates after implementation of preoperative SA decolonization regimens. (1,5,6,13-15) However, other studies have failed to demonstrate this effect. (16) As a result, SA decolonization protocols are not in widespread use. Consequently, further randomized controlled trials are needed to determine their value in general surgical settings.

Even in appropriate study populations where SA decolonization regimens are implemented, SA induced SSIs still occur. (8,14,17) In these settings, measures taken to maximize patient participation in SA decolonization protocols would be beneficial to both patient and provider. Buehlmann and colleagues (18) have shown that success of SA decolonization and the subsequent SSI risk reduction is contingent upon the method of decolonization and patient compliance with the decolonization regimen. As a result, improving patient compliance should be a focus of SA decolonization programs with the end goal of further enhanced patient outcomes and maximal reduction in SSI rates.

In this study, of those patients who received SA decolonization instructions, 81% followed the MO protocol while 89% followed the protocol for pre-operative CHG use. Those who followed the MO protocol reported out of pocket expenses as well as some difficulty obtaining the product. Compliance despite these barriers indicates a concern with infection and demonstrates a motivation for performing infection prevention measures. However, even with this motivation, some patients may have been prevented from completing the protocol for other reasons. At our hospital, the date of patient PAT attendance is variable. The MO component of the SA decolonization regimen requires a 5-day course of treatment. For those patients who attended PAT and received the protocol less than 5 days prior to surgery, there would be inadequate time to fully complete the antibiotic regimen. As such, scheduling issues are another potential explanation for noncompliance. Given the patient survey responses, we hypothesize improved compliance could be achieved if MO were provided to those patients with high out of pocket expenses or those who had difficulty purchasing or locating the product. Investigation into the logistics of PAT scheduling would also potentially enable the reduction of noncompliance due to time inappropriate scheduling of patient PAT appointments. Additionally, simplifying the method of CHG application could increase the probability of successful protocol completion.

At NYU Langone Hospital for Joint Diseases, the decolonization regimen is patient-directed and performed unsupervised outside the hospital setting. As such, patient compliance is a particularly important factor in the success of the SA eradication regimen. Although compliance and acceptance was fairly high, further efforts are underway to increase patient compliance with the pre-operative regimens.


While SA decolonization regimens have the potential to reduce postoperative SSI risk, they remain limited by the requirement of strict patient adherence to standardized protocols. Staphylococcus aureus decolonization regimens are largely performed independently by the patient without direct hospital supervision. An emphasis should be placed on streamlining various protocol procedures and assuring availability of necessary products to ensure successful completion. To our knowledge, this study is the first to determine patient compliance and attitude toward SA decolonization protocols. Further efforts to improve acceptance and compliance with SA decolonization protocols and studies to examine their effectiveness in reducing SSI rates in high risk orthopaedic populations are necessary.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.


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(5.) Nicholson MR, Kirk P, Robinson M, et al. Pre-operative Staphylococcus aureus nasal screening does reduce total joint surgical site infections. Am J Infect Control. 2006;34:E137-8.

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(8.) Schelenz S, Tucker D, Georgeu C, et al. Significant reduction of endemic MRSA acquisition and infection in cardiothoracic patients by means of an enhanced targeted infection control programme. J Hosp Infect. 2005;60(2):104-10.

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(15.) Bode MD, Kluytmans J, Wertheim HF, et al. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. New Engl J Med. 2010;362(1):9-17.

(16.) Harbarth S, Fankhauser C, Schrenzel J. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA. 2008;299(10):1149-57.

(17.) Awad SS, Palacio CH, Subramanian A, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg. 2009;198(5):607-10.

(18.) Buehlmann M, Frei R, Fenner L, et al. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol. 2008;29(6):510-6.

Nicholas Ramos, B.A., Faith Skeete, R.N., Janet P. Haas, DNSc, R.N., Lorraine Hutzler, B.A., James Slover, M.D., M.S., and Joseph Bosco, M.D., are in the Department of Orthopedic Surgery, NYU Langone Hospital for Joint Diseases, New York, New York. Michael Phillips, M.D., Department of Medicine (Infectious Disease and Immunology), NYU Langone Medical Center, New York, New York.

Correspondence: Nicholas Ramos, B.A., 334 East 26th Street Apartment 14B2, New York, New York 10010; nicholas.ramos@
Table 1 Questionnaire Survey Responses

Surveys Distributed                   146
Surveys returned                      100 (68%)
Age (Years): Mean (range)             55 (19-85)
Gender *                              Male             Female
                                      48/100 (48%)     50/100 (50%)

PAT attendance
Attended PAT and received protocol    85/100 (85%)
Did not attend PAT                    14/100 (14%)
Unable to recall PAT attendance       1/100 (1%)
Followed protocol for MO              69/85 (81%)
Followed protocol for CHG             76/85 (89%)

MO Ease of Compliance                                  Mean (Range)
Followed Protocol                     69/85 (81%)
Out of pocket expense                 37/69 (54%)      $25 ($2-$115)
Hard or very hard to purchase         9/69 (13%)
Difficult to locate                   4/69 (6%)

CHG Ease of Compliance
Follow Protocol                       76/85 (89%)
Easy or very easy to use              71/76 (93%)
Concerned about SSIs                  Yes              No
                                      46/100 (46%)     54/100 (54%)

* Two patients did not specify gender.
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