title: Predictive value and cost-effectiveness analysis of a rapid polymerase chain reaction for preoperative detection of nasal carriage of Staphylococcus aureus.
abstract: OBJECTIVE
  To determine the accuracy and cost-effectiveness of a polymerase chain reaction (PCR) for detecting nasal carriage of Staphylococcus aureus directly from clinical specimens. CROSS-SECTIONAL STUDY: This occurred in a tertiary-care hospital in Cleveland, Ohio, and included 239 consecutive patients who were scheduled for a cardiothoracic surgical procedure. Conventional cultures and a PCR for S. aureus from nasal swabs were used as measurements. COST-EFFECTIVENESS ANALYSIS: Data sources were market prices and Bureau of Labor Statistics. The time horizon was the maximum period for availability of culture results (3 days). Interventions included universal mupirocin therapy without testing; initial therapy, with termination if PCR negative (treat-PCR); initial therapy, with termination if culture negative (treat-culture); treat PCR-positive carriers (PCR-guided treatment); and treat culture-positive carriers (culture-guided treatment). The perspective was institutional and costs and the length of time to treatment were outcome measures.
  
  
  RESULTS
  Sixty-seven (28%) of the 239 swabs grew S. aureus. Rapid PCR was 97.0% sensitive and 97.1% specific for the detection of S. aureus. For populations with prevalences of nasal S. aureus carriage of up to 50%, the PCR assay had negative predictive values of greater than 97%. PCR-guided treatment had the lowest incremental cost-effectiveness ratio (1.93 dollars per additional day compared with the culture strategy). Among immediate treatment strategies, treat-PCR was most cost-effective. The universal therapy strategy cost 38.19 dollars more per additional day gained with carrier identification compared with the PCR strategy.
  
  
  CONCLUSIONS
  Rapid real-time PCR is an accurate, rapid, and cost-effective method for identifying S. aureus carriers for preoperative intervention.
authors.affiliation: The Cleveland Clinic Foundation, Ohio 44195, USA.
authors.forename: Nabin K
authors.initials: NK
authors.lastname: Shrestha
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Shermock
authors.forename: Steven M
authors.initials: SM
authors.lastname: Gordon
authors.forename: Marion J
authors.initials: MJ
authors.lastname: Tuohy
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Wilson
authors.forename: Roberta E
authors.initials: RE
authors.lastname: Cwynar
authors.forename: Michael K
authors.initials: MK
authors.lastname: Banbury
authors.forename: David L
authors.initials: DL
authors.lastname: Longworth
authors.forename: Carlos M
authors.initials: CM
authors.lastname: Isada
authors.forename: Steven D
authors.initials: SD
authors.lastname: Mawhorter
authors.forename: Gary W
authors.initials: GW
authors.lastname: Procop
mesh_terms: D000465:Algorithms; D001483:Base Sequence; D002353:Carrier State; D003362:Cost-Benefit Analysis; D017931:DNA Primers; D006801:Humans; D016712:Mupirocin / Q000627:therapeutic use; D009296:Nasal Cavity / Q000382:microbiology*; D009820:Ohio; D016133:Polymerase Chain Reaction / Q000191:economics / Q000379:methods*; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000191:economics*; D015995:Prevalence; D012680:Sensitivity and Specificity; D013211:Staphylococcus aureus / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification*; D019616:Thoracic Surgical Procedures
chemical_list: D017931:DNA Primers; D016712:Mupirocin