Abstract
OBJECTIVE: Cephalosporins are recommended for antibiotic prophylaxis to prevent cardiothoracic surgical site infections (SSIs) except in patients with β-lactam allergy or in settings with a "high" prevalence of methicillin-resistant Staphylococcus aureus (MRSA) among S. aureus isolates (hereafter, "MRSA prevalence"); however, "high" remains undefined. We sought to identify the MRSA prevalence at which glycopeptide prophylaxis would minimize SSIs relative to β-lactam prophylaxis. METHODS: We developed a decision analysis model to estimate SSI likelihood when either glycopeptides or β-lactams were used for prophylaxis in cardiothoracic surgery. Event probabilities were derived from a systematic literature review. A similar cost-minimization model was also developed. RESULTS: At 0% MRSA prevalence, SSI probability was 3.64% with glycopeptide prophylaxis and 3.49% with β-lactam prophylaxis. At MRSA prevalences of 10%, 20%, 30%, or 40%, SSI probabilities with glycopeptide prophylaxis did not change, but they were 3.98%, 4.48%, 4.97%, and 5.47% with β-lactam prophylaxis. The threshold of MRSA prevalence at which glycopeptide prophylaxis minimized SSI probability and cost was 3%. In sensitivity analyses, variations in most model estimates only modestly affected the threshold. CONCLUSION: Glycopeptide prophylaxis minimizes the risk of SSIs and cost when MRSA prevalence exceeds 3%. At very low MRSA prevalence (between 3% and 10%), the SSI minimization provided by glycopeptide prophylaxis is small and may be within the error of the model. Given the current MRSA prevalence in most community and healthcare settings, clinicians should consider routine prophylaxis with vancomycin. Our findings may have important policy implications, as benefits in cardiothoracic surgery antibiotic prophylaxis must be weighed against the limitations of increased glycopeptide use.