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World J Emerg Surg. 2017 Jun 12;12:25. doi: 10.1186/s13017-017-0136-3. eCollection 2017.

Early recognition of methicillin-resistant Staphylococcus aureus surgical site infections using risk and protective factors identified by a group of Italian surgeons through Delphi method.

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Istituto Clinica Chirurgica, Divisione Chirurgia Generale e del Trapianto di Fegato, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli, Largo Gemelli, 8, 00168 Roma, Italia.
Prima Divisione Malattie Infettive, Azienda Ospedaliera dei Colli, Napoli, Italia.
U.O. Medicina d'Urgenza Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italia.
Master Sepsi in Chirurgia, Università Cattolica del Sacro Cuore, Roma, Italia.



Surgical site infections (SSIs) constitute a major clinical problem in terms of morbidity, mortality, duration of hospital stay, and overall costs. The bacterial pathogens implicated most frequently are Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus). The incidence of methicillin-resistant S. aureus (MRSA) SSIs is increasing significantly. Since these infections have a significant impact on hospital budgets and patients' health, their diagnosis must be anticipated and therapy improved. The first step should be to evaluate risk factors for MRSA SSIs.


Through a literature review, we identified possible major and minor risk factors for, and protective factors against MRSA SSIs. We then submitted statements on these factors to 228 Italian surgeons to determine, using the Delphi method, the degree of consensus regarding their importance. The consensus was rated as positive if >80% of the voters agreed with a statement and as negative if >80% of the voters disagreed. In other cases, no consensus was reached.


There was positive consensus that sepsis, >2 weeks of hospitalization, age >75 years, colonization by MRSA, and diabetes were major risk factors for MRSA SSIs. Other possible major risk factors, on which a consensus was not reached, e.g., prior antibiotic use, were considered minor risk factors. Other minor risk factors were identified. An adequate antibiotic prophylaxis, laparoscopic technique, and infection committee surveillance were considered protective factors against MRSA SSIs. All these factors might be used to build predictive criteria for identifying SSI due to MRSA.


In order to help to recognize and thus promptly initiate an adequate antibiotic therapy for MRSA SSIs, we designed a gradation of risk and protective factors. Validation, ideally prospective, of this score is now required. In the case of a SSI, if the risk that the infection is caused by MRSA is high, empiric antibiotic therapy should be started after debriding the wound and collecting material for culture.


Acute bacterial skin and skin structure infections; Dalbavancin; MRSA; Surgical site infection

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