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In the most recent report from the Centers for Disease Control and Prevention's National Healthcare Safety Network in 2019, which reviewed data across the United States from 2015 to 2017, S aureus was the most common organism implicated in surgical site infections (5515), serving as the causative agent in 17.5% of all reported SSIs.3 This number was even more staggering in orthopedic and cardiac surgeries, with S aureus causing 38.6% of all reported orthopedic infections and 27% of all cardiac surgery infections.3 Although 5 aureus continues to cause a significant number of SSIs both in the United States and internationally, the best targeted infection prevention interventions have been debated in the literature. In the 2014 updates to the SHEA/IDSA guidelines, screening for 5 aureus in orthopedic and cardiothoracic surgery patients and decolonizing those patients who screened positive was listed as moderate-quality evidence.4 In the 2022 update to the SHEA/IDSA guidelines, the level of evidence for decolonizing patients undergoing orthopedic and cardiothoracic procedures was upgraded to high-quality evidence, and was even added to the list of essential practices in their guidelines for SSI prevention.5 As the evidence continues to support S aureus as the most common cause of SSIs and the quality of evidence for decolonization continues to increase, hospitals across the country must ensure they have a program in place that supports best practices and reduces the risk of S aureus SSIs in all orthopedic and cardiothoracic surgery patients. To help support hospitals in implementing these best practices, the Agency for Healthcare Research and Quality (AHRQ) released its MRSA Prevention Toolkit: Targeting SSI (https:/www.ahrq.gov/hai/tools/mrsa-prevention/surge ry/index.html) in April 2025.6 TOOLKIT OVERVIEW Similar to the recommendations in the SHEA/IDSA guidelines, the AHRQ MRSA Prevention Toolkit focuses on interventions in cardiothoracic surgery, orthopedic joint replacements, and spine surgery.6 The AHRQ toolkit breaks down MRSA SSI prevention into four key strategies. Preeti Mehrotra, MD, MPH, senior medical director, Infection Control/Hospital Epidemiology Division of Infectious Diseases, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston, MA.
Staphylococcus aureus is a gram-positive bacterium that can commonly be found on the skin or in the nares of approximately 30% of the population without actively causing an infection, also known as colonization.1 Staphylococcus aureus can be susceptible to many antibiotics, including beta-lactams such as oxacillin and methicillin, at which point the S aureus would be referred to as "methicillin-susceptible S aureus (MSSA)." Staphylococcus aureus also can develop resistance to beta-lactams, at Which point it is referred to as "methicillin-resistant S aureus (MRSA)." Although far less common, S aureus can also be resistant to vancomycin, one of the main agents used to treat MRSA, at which point it would be referred to as "vancomycin-intermediate S aureus (VISA) or "vancomycin-resistant S aureus (VRSA)."1
Staphylococcus aureus transmission has long been a concern in all areas of health care since MRSA was first detected in 1961,2 and 5 aureus is an even greater concern in the surgical setting. In the most recent report from the Centers for Disease Control and Prevention's National Healthcare Safety Network in 2019, which reviewed data across the United States from 2015 to 2017, S aureus was the most common organism implicated in surgical site infections (5515), serving as the causative agent in 17.5% of all reported SSIs.3 This number was even more staggering in orthopedic and cardiac surgeries, with S aureus causing 38.6% of all reported orthopedic infections and 27% of all cardiac surgery infections.3 Although 5 aureus continues to cause a significant number of SSIs both in the United States and internationally, the best targeted infection prevention interventions have been debated in the literature.
One of the leading guidelines on SSI prevention is the ciety for Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA)'s Strategies to Prevention Surgical Site Infections in Acute Care Hospitals. In the 2014 updates to the SHEA/IDSA guidelines, screening for 5 aureus in orthopedic and cardiothoracic surgery patients and decolonizing those patients who screened positive was listed as moderate-quality evidence.4 In the 2022 update to the SHEA/IDSA guidelines, the level of evidence for decolonizing patients undergoing orthopedic and cardiothoracic procedures was upgraded to high-quality evidence, and was even added to the list of essential practices in their guidelines for SSI prevention.5
As the evidence continues to support S aureus as the most common cause of SSIs and the quality of evidence for decolonization continues to increase, hospitals across the country must ensure they have a program in place that supports best practices and reduces the risk of S aureus SSIs in all orthopedic and cardiothoracic surgery patients. To help support hospitals in implementing these best practices, the Agency for Healthcare Research and Quality (AHRQ) released its MRSA Prevention Toolkit: Targeting SSI (https:/www.ahrq.gov/hai/tools/mrsa-prevention/surge ry/index.html) in April 2025.6
TOOLKIT OVERVIEW
Similar to the recommendations in the SHEA/IDSA guidelines, the AHRQ MRSA Prevention Toolkit focuses on interventions in cardiothoracic surgery, orthopedic joint replacements, and spine surgery.6 The AHRQ toolkit breaks down MRSA SSI prevention into four key strategies. The strategies include the following.
* Nasal decolonization. With 5 aureus frequently colonizing the nares, the AHRQ provides evidence to support nasal decolonization as well as implementation guides for both universal and targeted nasal decolonization strategies.
* Preoperative skin antisepsis. Decolonizing the patient's skin of S aureus with chlorhexidine gluconate (CHG) can also help reduce the risk of SSI after surgery. The AHRQ toolkit provides implementation guides that list the pros and cons of the use of 4% CHG soap compared to 2% CHG wipes, and how facilities can ensure decolonization is completed before surgery.
* Antimicrobial prophylaxis. For orthopedic joint replacement, cardiothoracic surgery, and spine surgery, the recommended preoperative antimicrobial prophylaxis is similar. Cefazolin is the recommended agent for patients without a history of or risk factors for MRSA, while vancomycin is used for those with a MRSA history or risk factors for MRSA.6 The AHRQ toolkit highlights the agent, time, dose, and duration in their antimicrobial prophylaxis basics, and dives deeper into specifics, such as the use of topical antibiotics intraoperatively in their "Beyond the Basics" resources.6
* Evidence-based infection prevention. The AHRQ toolkit also highlights evidence-based infection prevention practices that are used to prevent SSIs more broadly. These practices include reducing traffic in the ORs; maintaining normothermia; and performing preoperative patient skin antisepsis, hair removal (only when necessary), hand hygiene, and environmental cleaning,6 all of which are also highlighted in the AORN Guidelines for Perioperative Practice.7 One controversial practice that is highlighted in the toolkit is the use of contact precautions for patients with MRSA infection or colonization. Although this practice was a standard at one time, a recent survey through the SHEA Research Network identified that 43% of facilities surveyed no longer use contact precautions for MRSA,8 and data from those facilities that have discontinued contact precautions for MRSA have not shown an increase in MRSA infections or transmission events.9 Perioperative teams should consult with their infection prevention teams to review their facility's practices related to contact precautions.
Phases of SSI Prevention
With the four key strategies identified, the AHRQ outlines how these strategies can be implemented in each phase of care for the surgical patient. These phases include the office/home phase, the preoperative phase, the surgery phase, and the postoperative phase. Many of the interventions are similar throughout the phases, but implementation in each phase may look slightly different and need to be implemented by different staff members. Ensuring staff members for all phases of care are part of the MRSA SSI prevention plan is key for successful implementation of the toolkit.6
Implementation
As with many quality improvement initiatives, the implementation of the program can be the most daunting. The AHRQ toolkit provides a structured guide to operationalizing the MRSA SSI prevention program at local facilities, including gap analysis tools for both the hospital-wide program and the program within the perioperative services division. There are also prebuilt tools for the nization program and to support staff members having ownership and involvement in the SSI prevention process at their local institution.6
In addition to the implementation tools available, the Comprehensive Unit-based Safety Program (CUSP) from the AHRQ provides a structured quality improvement framework to guide the implementation of a MRSA SSI prevention program. Similar to other quality improvement frameworks, the CUSP is built around a culture of continuous improvement supported by the "4 Es": Engage, Educate, Execute, Evaluate. This four-step process allows for the implementation of the ARHQ toolkit using a proven, structured approach that supports staff member engagement, psychological safety, and sustainability.10
CONCLUSION
As S aureus, including MRSA, continues to cause a significant number of SSIs across the United States, all evidencebased interventions to help reduce the risk of infection should be considered. The AHRQ MRSA SSI Toolkit: Targeting SSI provides perioperative and infection prevention teams a structured guide to implementing best practices for S aureus SSI prevention for patients undergoing joint replacement, cardiac surgery, and spine surgery
REFERENCES
1. Staphylococcus aureus basics. Centers for Disease Control and Prevention. April 15, 2024. Accessed August 8, 2025. https:/www.cdc.gov/staphylococcus-aureus/about/index. html
2. Enright MC, Robinson DA, Randle G, Feil EJ, Grundmann H, Spratt BG. The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). Proc Natl Acad Sci U S A. 2002;99(11):7687-7692. https://doi.org/10.1073/pnas.12 2108599
3. Weiner-Lastinger LM, Abner S, Edwards JR, et al. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020;41(1):1-18. https://doi. org/10.1017/ice.2019.296
4. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(S2):S66-S88. https://doi.org/10.1017/S0899823 X00193869
5. Calderwood MS, Anderson DJ, Bratzler DW, et al. Strategies to prevent surgical site infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2023;44(5):695-720. https://doi.org/10.1017/ice.2023. 67
6. MRSA Prevention Toolkit: Targeting SSI. Agency for Healthcare Research and Quality. April 2025. Accessed August 8, 2025. https://www.ahrq.gov/hai/tools/mrsa-prevention/ surgery/index.html
7. Guidelines for Perioperative Practice. AORN. Accessed April 10, 2024. https://www.aorn.org/guidelines-resources/guidelines-for-perioperat?ive-practice
8. Martin E, Morgan DJ, Pryor R, Bearman G. Contact precautions for MRSA and VRE: where are we now? A survey of the Society for Healthcare Epidemiology of America Research Network. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e137. https://doi.org/10.1017/ash.2024.350
9. Karunakaran S, Pless LL, Ayres AM, et al. Impact of discontinuation of contact precautions on surveillance- and whole genome sequencing-defined methicillin-resistant Staphylococcus aureus healthcare-associated infections. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e97. https://doi.org/ 10.1017/ash.2024.89
10. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention. MRSA Prevention Toolkit: Targeting SSI. Agency for Healthcare Research and Quality. April 2025. Accessed August 8, 2025. https://www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
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