Management of Patients with Prior MRSA Infection Undergoing Surgery
Preoperative Management
- The 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, 2
- Prior MRSA infection is the most reliable predictor for MRSA colonization, making this patient high-risk regardless of screening results 4
- 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) 3, 2
Intraoperative Management
- Add vancomycin to standard surgical prophylaxis for this patient with documented prior MRSA infection 7, 8
- Standard prophylaxis PLUS vancomycin is recommended for patients with prior MRSA infection or colonization within the past year 7, 8
- Vancomycin dosing: Administer as a weight-based infusion (typically 15 mg/kg) started 1-2 hours before incision to ensure adequate tissue levels 8
Postoperative Management
- Monitor closely for surgical site infection with a low threshold for culture and empiric MRSA coverage if infection develops 7, 4
- Inspect the surgical site carefully starting 48 hours postoperatively, as SSIs rarely occur in the first 48 hours 7
- Obtain wound cultures if infection is suspected 7
- Empiric antibiotic therapy for SSI should cover MRSA in this patient given prior infection history 7, 4