Pre-Operative Management for MRSA-Colonized Patients Before Orthopedic Surgery

Decolonization Protocol

• The European guidelines recommend a 5-day decolonization protocol with intranasal mupirocin 2% twice daily combined with daily chlorhexidine gluconate 4% body wash, completed 1-2 weeks before orthopedic surgery, for patients with positive MRSA nares colonization 1, 2, 3
• The combination of mupirocin and chlorhexidine is more effective than mupirocin alone, with studies showing significant reductions in surgical site infections in orthopedic surgery patients, providing strong evidence for this approach 1, 4
• The decolonization regimen should be completed as close as possible to the operation, with the goal of finishing 1-2 weeks before the scheduled surgery date 1

Surgical Prophylaxis Modification

• The patient requires modified antibiotic prophylaxis on the day of surgery, with vancomycin added to the standard surgical prophylaxis regimen, typically a cephalosporin, for MRSA-colonized patients undergoing orthopedic surgery 3, 5
• Vancomycin should be administered at a dose of 15 mg/kg as an infusion starting 1-2 hours before incision to ensure adequate tissue levels, although this specific dosing guideline is based on general surgical prophylaxis principles 6
• The standard prophylaxis agent should not be replaced with vancomycin; instead, vancomycin should be added to the standard regimen 3, 5

Post-Operative Considerations

• Enhanced surveillance for surgical site infection is recommended, with close monitoring of the surgical site starting 48 hours postoperatively, and a low threshold for obtaining wound cultures if any signs of infection develop 6
• Any suspected infection should be treated empirically with MRSA-active antibiotics given the documented colonization history 6