What are the preoperative, intraoperative, and postoperative steps for a patient with a history of Methicillin-resistant Staphylococcus aureus (MRSA) infection undergoing a Lapidus bunionectomy?

Management of 26-Year-Old with Prior MRSA Undergoing Lapidus Bunionectomy

Preoperative Management

This patient with a history of MRSA infection should undergo preoperative MRSA screening followed by decolonization with mupirocin nasal ointment 2% twice daily for 5 days combined with chlorhexidine gluconate 4% body wash, completed 1-2 weeks before surgery. 1

Screening Protocol

• Screen for MRSA colonization before elective orthopedic surgery using nasal swabs (and consider additional sites including groin and perianal areas, as 5% of carriers may have negative nasal cultures but positive cultures elsewhere) 1, 2
• Rapid screening methods (e.g., PCR) can provide timely results for preoperative assessment 1
• Prior MRSA infection is the most reliable predictor for MRSA colonization, making this patient high-risk regardless of screening results 1

Decolonization Protocol (If MRSA-Positive or High-Risk)

• Mupirocin 2% nasal ointment: Apply to anterior nares twice daily for 5-10 days 1, 3
• Chlorhexidine gluconate 4% body wash: Daily full-body washing during the 5-day treatment period 1, 3
• Timing is critical: Complete decolonization 1-2 weeks before surgery 1, 3
• If the 5-day decolonization course cannot be completed preoperatively, complete it postoperatively 1
• For elective procedures, consider postponing surgery to complete decolonization if feasible 1, 3

Additional Preoperative Considerations

• Optimize wound care and hygiene measures 3
• Reinforce environmental hygiene: clean high-touch surfaces that may contact bare skin 3, 4
• Avoid sharing personal items 4

Intraoperative Management

Add vancomycin to standard surgical prophylaxis for this patient with documented prior MRSA infection. 1

Antibiotic Prophylaxis

• Standard prophylaxis PLUS vancomycin is recommended for patients with prior MRSA infection or colonization within the past year 1
• Vancomycin dosing: Administer as a weight-based infusion (typically 15 mg/kg) started 1-2 hours before incision to ensure adequate tissue levels 1
• Alternative: High-dose teicoplanin (10-12 mg/kg) may be considered, though evidence is more limited 1
• Continue standard gram-positive coverage (first-generation cephalosporin) alongside vancomycin for comprehensive prophylaxis 1

Surgical Technique Considerations

• Maintain meticulous sterile technique and standard infection control measures 1
• Ensure adequate source control and hemostasis 1

Postoperative Management

Monitor closely for surgical site infection with a low threshold for culture and empiric MRSA coverage if infection develops. 1

Surveillance and Monitoring

• Inspect the surgical site carefully starting 48 hours postoperatively, as SSIs rarely occur in the first 48 hours 1
• Monitor for signs of infection: purulent drainage, erythema extending >5 cm from wound edge, fever >38.5°C, or systemic signs 1
• MRSA SSI risk is 3.4% in colonized orthopedic patients despite decolonization, with increased risk in patients with prosthetic material 5

Management of Suspected SSI

• Obtain wound cultures if infection is suspected 1
• For superficial SSI: Perform suture removal and incision/drainage 1
• Empiric antibiotic therapy for SSI should cover MRSA in this patient given prior infection history 1
  • Options include: vancomycin, linezolid, daptomycin, telavancin, or ceftaroline 1
  • Linezolid showed superior MRSA eradication compared to vancomycin in one trial (RR 1.80,95% CI 1.20-2.68), though clinical implications remain unclear 6

Duration of Therapy

• Brief course (typically 5-7 days) for superficial SSI with systemic signs 1
• Longer duration if deep infection or osteomyelitis develops 1
• Adjust antibiotics based on culture results and clinical response 1

Additional Postoperative Measures

• Complete any remaining decolonization protocol if not finished preoperatively 1
• Maintain wound coverage with clean, dry bandages 4
• Continue hand hygiene and environmental cleaning measures 3, 4
• Monitor for increased hospital length of stay: MRSA infections are associated with 29.6 days vs. 22.7 days for other infections 7

Critical Pitfalls to Avoid

• Do not skip decolonization in patients with prior MRSA infection—this is the single most important modifiable risk factor 1, 3
• Do not use standard prophylaxis alone without vancomycin coverage in this high-risk patient 1
• Do not delay empiric MRSA coverage if postoperative infection develops—prior MRSA infection mandates immediate coverage 1
• Do not assume negative nasal screening excludes colonization—consider multi-site screening 2