Surgical neuromodulation: prevalence of Staphylococcus aureus, decolonization, and rates of infection

Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) are known to colonize various bodily locations and present unique challenges in the prevention and treatment of deep surgical site infections (SSIs). The aim of this study was to determine if preoperative colonization testing and decolonization protocols reduce the rate of SSIs in patients undergoing surgical neuromodulation procedures.

Using a prospectively maintained database, a single-surgeon, single-facility, retrospective study identified 513 spinal cord stimulation (SCS) procedures, 1050 deep brain stimulation (DBS) procedures, and 414 intrathecal baclofen (ITB) pump procedures performed between June 2013 and June 2024. These procedures were performed in 361 patients receiving SCS devices, 375 patients receiving DBS devices, and 308 patients receiving ITB pumps. Preoperative S. aureus nasal swab results, postoperative superficial and deep SSIs requiring device removal, and patient-related comorbidities were analyzed. Patients were monitored for at least 6 months postoperatively for deep SSIs. Different perioperative colonization screening, decolonization, and antibiotic protocols were assessed.

Approximately 20% of all patients undergoing implantation of SCS/DBS devices and 25% of patients undergoing implantation of ITB devices had positive results for S. aureus. MSSA colonization was 14 times more common than MRSA colonization in patients who underwent SCS procedures, 9 times more common in those who underwent DBS procedures, and 3 times more common in those who underwent ITB pump procedures. MRSA colonization was 3 times more common in patients who underwent ITB pump procedures than in those who underwent SCS/DBS procedures. There were no deep SSIs in the SCS group. Patients in the ITB pump group had a decrease in infection rate from 8% down to < 2% after implementation of preoperative decolonization protocols.

This study represents the most comprehensive report to date analyzing the prevalence of preoperative MRSA and MSSA colonization in patients undergoing a wide array of surgical neuromodulation procedures. These data support the recommendation that patients receiving neuroimplantable devices, specifically patients undergoing ITB pump procedures, be 1) screened for both MRSA and MSSA, as screening for MRSA alone will not reveal a large fraction of S. aureus colonization; and 2) considered for decolonization protocols prior to surgery. Following these procedures significantly reduced SSIs in patients who underwent ITB pump implantation procedures and might have reduced SSIs for SCS and DBS implantation procedures as well.