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Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis

BMJ 2013; 346 doi: (Published 13 June 2013) Cite this as: BMJ 2013;346:f2743
  1. Marin Schweizer, assistant professor123,
  2. Eli Perencevich, professor1234,
  3. Jennifer McDanel, student research assistant2,
  4. Jennifer Carson, research assistant1,
  5. Michelle Formanek, student research assistant23,
  6. Joanne Hafner, associate project director5,
  7. Barbara Braun, project director5,
  8. Loreen Herwaldt, professor124
  1. 1University of Iowa Carver College of Medicine, Iowa City, IA, USA
  2. 2University of Iowa College of Public Health, Iowa City, IA, USA
  3. 3Iowa City VA Health Care System, Mailstop 152, 601 Hwy 6 West, Iowa City, IA 52246, USA
  4. 4Office of Clinical Quality, Safety, and Performance Improvement, and the Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
  5. 5The Joint Commission, Oakbrook Terrace, IL, USA
  1. Correspondence to: M Schweizer marin-schweizer{at}
  • Accepted 16 April 2013


Objective To evaluate studies assessing the effectiveness of a bundle of nasal decolonization and glycopeptide prophylaxis for preventing surgical site infections caused by Gram positive bacteria among patients undergoing cardiac operations or total joint replacement procedures.

Design Systematic review and meta-analysis.

Data sources PubMed (1995 to 2011), the Cochrane database of systematic reviews, CINAHL, Embase, and were searched to identify relevant studies. Pertinent journals and conference abstracts were hand searched. Study authors were contacted if more data were needed.

Eligibility criteria Randomized controlled trials, quasi-experimental studies, and cohort studies that assessed nasal decolonization or glycopeptide prophylaxis, or both, for preventing Gram positive surgical site infections compared with standard care.

Participants Patients undergoing cardiac operations or total joint replacement procedures.

Data extraction and study appraisal Two authors independently extracted data from each paper and a random effects model was used to obtain summary estimates. Risk of bias was assessed using the Downs and Black or the Cochrane scales. Heterogeneity was assessed using the Cochran Q and I2 statistics.

Results 39 studies were included. Pooled effects of 17 studies showed that nasal decolonization had a significantly protective effect against surgical site infections associated with Staphylococcus aureus (pooled relative risk 0.39, 95% confidence interval 0.31 to 0.50) when all patients underwent decolonization (0.40, 0.29 to 0.55) and when only S aureus carriers underwent decolonization (0.36, 0.22 to 0.57). Pooled effects of 15 prophylaxis studies showed that glycopeptide prophylaxis was significantly protective against surgical site infections related to methicillin (meticillin) resistant S aureus (MRSA) compared with prophylaxis using β lactam antibiotics (0.40, 0.20 to 0.80), and a non-significant risk factor for methicillin susceptible S aureus infections (1.47, 0.91 to 2.38). Seven studies assessed a bundle including decolonization and glycopeptide prophylaxis for only patients colonized with MRSA and found a significantly protective effect against surgical site infections with Gram positive bacteria (0.41, 0.30 to 0.56).

Conclusions Surgical programs that implement a bundled intervention including both nasal decolonization and glycopeptide prophylaxis for MRSA carriers may decrease rates of surgical site infections caused by S aureus or other Gram positive bacteria.


  • We thank the following for contributing additional data from their research, which allowed us to improve the quality of the study: Trish M Perl, M Bridget Zimmerman, Karolin Graf, Kalpana Gupta, Lorraine Hutzler, Urs Niederhauser, Ann Bull, Scott Sporer, Lonneke Bode, and Jenni Steinbrunner; and Michele Bozikis, Edward Septimus, and the Technical Expert Panel, including Michael Banbury, Dale Bratzler, Joseph Buckwalter, E Patchen Dellinger, Richard Embrey, Stephan Harbarth, Keith Kaye, Matthew Koff, Randy Loftus, Vincent Pellegrini, James Steinberg, and Edward Wong who contributed to this work; and the Iowa City VA Health Care System for its support. This study was presented in part at the 49th annual Infectious Diseases Society of America meeting. Boston, MA, October, 2011. This research was conducted by investigators at the University of Iowa and The Joint Commission under contract to the Agency for Healthcare Research and Quality. The authors of this article are responsible for the content. No statement may be construed as the official position of the Agency for Healthcare Research and Quality of the US Department of Health and Human Services.

  • Contributors: MLS, ENP, JH, BB, and LAH designed the study. MLS, JM, and JC performed the literature search. MLS, ENP, and LAH abstracted data. MF compared reviewer forms and assisted in the meta-analyses. MLS performed the meta-analyses. MLS, ENP, JH, BB, and LAH wrote the report. All authors read and approved the final version before submission. MLS is the guarantor.

  • Funding: This project was funded by the Agency for Healthcare Research and Quality (contract No HHSA290200600021I) of the US Department of Health and Human Services. The sponsors played no role in the study design, data collection and analysis, or decision to submit the article for publication. MLS was supported by the University of Iowa clinical and translational science award (NIH/NCRR-3KL2 RR024980-04S1). ENP was funded through a VA Health Services and Research and Development Service grant (No 09-099).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any company for their submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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