MRSA FOLLOWING DISCECTOMY

Case Overview:

Client has a known and documented history of MRSA within 3 months of discectomy. Patient is given Ancef only 26 minutes into the surgery. No additional perioperative or postoperative antibiotics. Client develops severe MRSA infection including osteomyelitis of the lumbar spine and pelvis.

Issue:

Was the potentiality for a post- operative infection properly managed?

Was Ancef the correct antibiotic?

Should additional measures have been taken regarding to reduce the likelihood of a MRSA infection?

MEDQUEST EXPERT RESPONSES:

Ancef is a reasonable antibiotic to administer as a prophylactic agent to reduce the risk of infection It only has to be given once at the start of the case. The usual routine is for the antibiotic to be given before the skin incision because the literature identifies the need for there to be blood levels of the antibiotic at the time of the incision. There is no significant evidence that identifies that more antibiotics after the operation would be beneficial. Therefore, it is not the standard of care to give antibiotics after the operation even though many people give an extra dose or two. Your information implies that the antibiotic was given 26 minutes after the incision. Is that correct? If so, this may be a breach in the standard of care that would increase the risk of infection. Proper administration of the antibiotic before the incision would not eliminate the risk of infection. However, it would reduce the risk of infection compared to no antibiotic or one given after the incision was made.
Dr SB – Neurosurgery

This is a difficult question because of the tremendous controversy regarding this issue. It is certainly not a standard of care to not use cefazolin in the instance of prior history of of MRSA unless there is an active skin infection. I looked at this recent publication of ASHP Therapeutic Guidelines (attached). They state “Vancomycin prophylaxis should be considered for patients with known MRSA colonization or at high risk for MRSA colonization in the absence of surveillance data” but also is noted that “data suggest that vancomycin is less effective than cefazolin for preventing SSIs caused by methicillin-susceptible Sa.ureus(MSSA)”.http://www.ashp.org/DocLibrary/BestPractices/TGSurgery.aspx
Dr JH –Neurosurgery

This is complicated case and would have to review it detail. If patient had documented MRSA recently as noted and given only cefazolin (Ancef) without re-eval for MRSA, de-colonization, this could be a problem. Issue may be good vs. standard of care which may be different here.
Dr HH – Infectious Disease