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For comparisons of adherence by operative period, a P value less than. All analyses were performed using SAS version 9. A total of patients underwent open airway operations. Of these, 5 patients were excluded owing to unclear documentation of screening; the remaining operations were included in this study.

Demographic data and baseline characteristics of this study population are presented in Table 1.

Treatment protocols for infections, MRSA vary throughout Europe

In addition, there were no significant differences between these 2 groups with regard to the percentage of patients who underwent 2-stage vs single-stage procedures or the percentage of those with a history of tracheotomy placement. The overall prevalence of MRSA in the study was As shown, postoperative infection rates were similar between the 2 groups.

One MRSA-colonized patient underwent a laryngotracheal separation but was not treated according to protocol. This patient developed a surgical site MRSA abscess that resolved after incision, drainage, and a course of intravenous vancomycin. Two laryngotracheal reconstruction cartilage graft failures and 1 dehiscence occurred. None of these events occurred in MRSA-colonized patients.

One graft failure was attributed to corticosteroid administration and impaired wound healing. The dehiscence was attributed to Haemophilus influenzae. Adherence to the complete protocol and to perioperative components of the protocol is presented in Table 4.

Adherence was especially problematic complete, To our knowledge, this is the first study to describe a screening and treatment MRSA protocol for pediatric patients undergoing open airway surgery. Based on prior experience, we considered these patients to be at high risk for colonization and the development of MRSA-associated surgical site infections. As anticipated, the prevalence of MRSA was high It was considerably higher than prevalence rates reported in patients undergoing other types of surgery.

Specifically, We consider these factors to be proxies for frequent hospitalization and exposure to antibiotics. This is consistent with reports that MRSA colonization may be greater in patients who have previously spent more than 5 days in an institutional setting and who have had frequent exposure to antibiotics. Quiz Ref ID During the study period, there were no MRSA-associated postoperative infections in patients treated according to our antibiotic protocol, which is consistent with reported findings in other studies.

Two patients treated according to protocol experienced graft loss or dehiscence associated with non-MRSA infection. This suggests that despite a screening and treatment protocol, there is an inherent risk of graft loss and dehiscence in all patients who undergo airway surgery. Infections other than MRSA may be causative factors.


Although complete adherence to all aspects of the protocol was lower than anticipated Unlike preoperative adherence, intraoperative, perioperative, and postoperative adherence was high Our study has several limitations. Because it is a retrospective analysis of our protocol, it is subject to the inherent limitations associated with all retrospective studies. Missing data, such as infections or complications, may have occurred but may not have been documented.

As well, a historical control group for direct comparison before institution of the protocol was not available.

Prior to this time, screening of patients was not performed. The protocol was instituted only after multiple catastrophic airway reconstruction failures concomitantly occurred with an associated MRSA infection. In view of this, clinicians believed that the risk of catastrophic airway failure merited the introduction of a standardized MRSA treatment protocol.

Future prospective studies in this patient population should further examine postoperative infection rates and specific treatment protocols. In conclusion, our study describes a screening and treatment MRSA protocol for pediatric patients undergoing airway surgery. In view of our results, we advise instituting MRSA screening and treatment protocols in patients undergoing airway surgery. Submitted for Publication: June 25, ; final revision received September 21, ; accepted November 16, Author Contributions: Drs Statham, de Alarcon, and Tabangin had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition of data : McCarty Statham. Critical revision of the manuscript for important intellectual content : de Alarcon, Tabangin, and Rutter. Statistical analysis : de Alarcon and Tabangin. Study supervision : de Alarcon and Rutter. Additional Contributions: Beverly Connelly, MD, director of the infection control program, assisted in the development of our antibiotic protocol.

All Rights Reserved. View Large Download. Table 1. Study Population Characteristics. Table 2. Table 3. Postoperative Infections by Treatment Group.

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Meticillin-resistant Staphylococcus aureus (MRSA): control and management

Table 4. Adherence to Antibiotic Protocol by Operative Period. Emergence and resurgence of meticillin-resistant Staphylococcus aureus as a public-health threat. Pediatric neck abscesses: changing organisms and empiric therapies. Nosocomial infections and hospital mortality: a multicentre epidemiology study.

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The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg. Clinical and economic impact of methicillin-resistant Staphylococcus aureus colonization or infection on neonates in intensive care units. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Am J Surg. An audit of prophylactic antibiotic use in laryngeal reconstruction surgery.

Int J Pediatr Otorhinolaryngol. Cost-effectiveness of universal MRSA screening on admission to surgery. Clin Microbiol Infect. Epidemiology and risk factors for hospital-acquired methicillin-resistant Staphylococcus aureus among burn patients. J Burn Care Res.

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For example, efforts to decolonize or eradicate MRSA from carrier patients through the use of systemic or topical antimicrobial agents should have an important effect on the likelihood of transmission. This practice has been applied in a number of settings for both MRSA and staphylococcal disease in general. With this in mind, to try to determine the impact of a screening program without detailed information about the deployment of decolonization measures is an important limitation to the available studies and has engendered considerable confusion among clinicians and policymakers.

In light of the promising, but limited evidence in support of active MRSA surveillance and in consideration of the important methodological questions previously noted, a systematic review of the evidence appears to be both justified and timely. The importance of gaining a better understanding of the evidence is further highlighted by the increasing demand for better control of MRSA and a higher standard for prevention of hospital-acquired infections in general.

Policymakers both within and outside of the U. The control of MRSA and other antibiotic-resistant bacteria has been highlighted as a likely target for pay-for-performance initiatives on the part of the U. Government and a number of private payers. The Joint Commission has highlighted the issue by identifying a National Patient Safety Goal regarding the control and prevention of antibiotic resistance.

In some cases, these legislative mandates have been issued even in the face of direct opposition from clinical experts in the field. The comments highlighted the controversies surrounding MRSA screening and the challenges inherent in a review of this topic. Based on the comments received, no changes were made to the key clinical questions. This section, in response to the public comments, provides additional details regarding the scope of the report and notes a change in the analytic framework Figures 1 and 2. The analytic framework had previously not illustrated the possibility that a patient who screens positive for MRSA would not be isolated but would instead be decolonized Figure 1 ; in response to the comments received, the analytic framework has been modified to include this possibility Figure 2.

Decolonization in the absence of screening can also occur. In addition, the optimal duration of isolation, the use of personal protective equipment by visitors, and the optimal decolonization regimen will not be formally evaluated. The review will consider a variety of screening types e. However, it will not formally evaluate the comparative effectiveness of screening at different sites or the optimal number of sampling sites. Because the harms of not screening patients for MRSA are to expose them to the risk of MRSA acquisition, infection, morbidity, and mortality, this review will indirectly address the harms of not screening.

In the absence of universal surveillance, unscreened patients may serve as a reservoir of infection.