Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey
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Prevention strategies are critical to reduce infection rates in total joint arthroplasty (TJA), but evidence-based consensus guidelines on prevention of surgical site infection (SSI) remain heterogeneous and do not necessarily represent this particular patient population.
What infection prevention measures are recommended by consensus evidence-based guidelines for prevention of periprosthetic joint infection? How do these recommendations compare to expert consensus on infection prevention strategies from orthopedic surgeons from the largest international tertiary referral centers for TJA?
Patients and Methods
A review of consensus guidelines was undertaken as described by Merollini et al. Four clinical guidelines met inclusion criteria: Centers for Disease Control and Prevention's, British Orthopedic Association, National Institute of Clinical Excellence's, and National Health and Medical Research Council's (NHMRC). Twenty-eight recommendations from these guidelines were used to create an evidence-based survey of infection prevention strategies that was administered to 28 orthopedic surgeons from members of the International Society of Orthopedic Centers. The results between existing consensus guidelines and expert opinion were then compared.
Recommended strategies in the guidelines such as prophylactic antibiotics, preoperative skin preparation of patients and staff, and sterile surgical attire were considered critically or significantly important by the surveyed surgeons. Additional strategies such as ultraclean air/laminar flow, antibiotic cement, wound irrigation, and preoperative blood glucose control were also considered highly important by surveyed surgeons, but were not recommended or not uniformly addressed in existing guidelines on SSI prevention.
Current evidence-based guidelines are incomplete and evidence should be updated specifically to address patient needs undergoing TJA.
- Adams, AL, Paxton, EW, Wang, JQ, Johnson, ES, Bayliss, EA, Ferrara, A, Nakasato, C, Bini, SA, Namba, RS (2013) Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am 95: pp. 481-7 CrossRef
- Bozic, KJ, Kurtz, SM, Lau, E, Ong, K, Vail, TP, Berry, DJ (2009) The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 91: pp. 128-33 CrossRef
- Bozic, KJ, Kurtz, SM, Lau, E, Ong, K, Chiu, V, Vail, TP, Rubash, HE, Berry, DJ (2010) The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 468: pp. 45-51 CrossRef
- Bozic, KJ, Lau, E, Kurtz, S, Ong, K, Rubash, H, Vail, TP, Berry, DJ (2012) Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 94: pp. 794-800
- Primary total hip replacement: a guide to good practice. British Orthopaedic Association, London
- Chiu, FY, Lin, CF, Chen, CM, Lo, WH, Chaung, TY (2001) Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomized study. J Bone Joint Surg Br 83: pp. 691-5 CrossRef
- Cummins, JS, Tomek, IM, Kantor, SR, Furnes, O, Engesaeter, LB, Finlayson, SR (2009) Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am 91: pp. 634-41 CrossRef
- Dale, H, Fenstad, AM, Hallan, G, Havelin, LI, Furnes, O, Overgaard, S, Pedersen, AB, Kärrholm, J, Garellick, G, Pulkkinen, P, Eskelinen, A, Mäkelä, K, Engesæter, LB (2012) Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop 83: pp. 449-58 CrossRef
- Dale, H, Hallan, G, Espehaug, B, Havelin, LI, Engesæter, LB (2009) Increasing risk of revision due to deep infection after hip Arthroplasty. Acta Orthop 80: pp. 6,639-45 CrossRef
- Danish Knee Arthroplasty register. Annual report 2010. Available: http://www.knee.dk/groups/dkr/pdf/DKRreportEnglish2010.pdf. Accessed: 4/21/2013.
- Dean, NC, Bateman, KA, Donnelly, SM, Silver, MP, Snow, GL, Hale, D (2006) Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest 130: pp. 794-9 CrossRef
- Espehaug, B, Engesaeter, LB, Vollset, SE, Havelin, LI, Langeland, N (1997) Antibiotic prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip replacements reported to the Norwegian Arthroplasty Register, 1987 to 1995. J Bone Joint Surg Br 79: pp. 590-595 CrossRef
- Everhart JS, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 2013;471:3112–3119.
- Gandhi, R, Razak, F, Pathy, R, Davey, JR, Syed, K, Mahomed, NN (2009) Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J Arthroplasty 24: pp. 1015-8 CrossRef
- Hepner, KA, Rowe, M, Rost, K, Hickey, SC, Sherbourne, CD, Ford, DE, Meredith, LS, Rubenstein, LV (2007) The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med 147: pp. 320-9 CrossRef
- Hsu, C, Cheng, SH (2009) Practice guideline adherence and health care outcomes—use of prophylactic antibiotics during surgery in Taiwan. J Eval Clin Pract 15: pp. 1091-6 CrossRef
- Iorio, R, Williams, KM, Marcantonio, AJ, Specht, LM, Tilzey, JF, Healy, WL (2012) Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty 27: pp. 726-9.e1 CrossRef
- Jämsen, E, Furnes, O, Engesæter, LB, Konttinen, YT, Odgaard, A, Stefánsdóttir, A, Lidgren, L (2010) Prevention of deep infection in joint replacement surgery a review. Acta Orthop 81: pp. 660-666 CrossRef
- Jämsen, E, Nevalainen, P, Eskelinen, A, Huotari, K, Kalliovalkama, J, Moilanen, T (2012) Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am 94: pp. e101 CrossRef
- Kim, DH, Spencer, M, Davidson, SM, Li, L, Shaw, JD, Gulczynski, D, Hunter, DJ, Martha, JF, Miley, GB, Parazin, SJ, Dejoie, P, Richmond, JC (2010) Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am 92: pp. 1820-6 CrossRef
- Kurtz, S, Ong, K, Lau, E, Mowat, F, Halpern, M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89: pp. 780-5 CrossRef
- Kurtz, SM, Lau, E, Watson, H, Schmier, JK, Parvizi, J (2012) Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 27: pp. 61-5.e1 CrossRef
- Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR (1999) the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection. Infect Control Hosp Epidemiol 20: pp. 247-280 CrossRef
- Marchant, MH, Viens, NA, Cook, C, Vail, TP, Bolognesi, MP (2009) The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am 91: pp. 1621-9 CrossRef
- Merollini, KM, Zheng, H, Graves, N (2013) Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline recommendations and expert opinion. Am J Infect Control 41: pp. 221-6 CrossRef
- Merollini, KM, Crawford, RW, Whitehouse, SL, Graves, N (2013) Surgical site infection prevention following total hip arthroplasty in Australia: a cost-effectiveness analysis. Am J Infect Control 41: pp. 803-809 CrossRef
- Namba, RS, Chen, Y, Paxton, EW, Slipchenko, T, Fithian, DC (2009) Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 24: pp. 44-7 CrossRef
- Namba, RS, Inacio, MC, Paxton, EW (2012) Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br 94: pp. 1330-8 CrossRef
- Namba, RS, Inacio, MC, Paxton, EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95: pp. 775-82 CrossRef
- National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. 2010. Available: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cd33_infection_control_healthcare_0.pdf. Accessed: 4/19/2013.
- National Institute for Health and Clinical Excellence. Prevention and Treatment of Surgical Site Infection. October 2008. Available: http://www.nice.org.uk/nicemedia/live/11743/42378/42378.pdf. Accessed 4/19/2013.
- Rao, N, Cannella, B, Crossett, LS, Yates, AJ, McGough, R (2008) A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res 466: pp. 1343-8 CrossRef
- Schrama, JC, Espehaug, B, Hallan, G, Engesaeter, LB, Furnes, O, Havelin, LI, Fevang, BT (2010) Risk of revision for infection in primary total hip and knee arthroplasty in patients with rheumatoid arthritis compared with osteoarthritis: a prospective, population-based study on 108,786 hip and knee joint arthroplasties from the Norwegian Arthroplasty Register. Arthritis Care Res (Hoboken) 62: pp. 473-9 CrossRef
- Swedish Knee Arthroplasty Register Annual Report 2012. Avaliable online. http://www.knee.nko.se/english/online/uploadedFiles//117_SKAR_2012_Engl_1.0.pdf. Accessed 4/20/2013.
- Tsaras, G, Osmon, DR, Mabry, T, Lahr, B, St Sauveur, J, Yawn, B, Kurland, R, Berbari, EF (2012) Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted County, Minnesota, 1969–2007. Infect Control Hosp Epidemiol 33: pp. 1207-12 CrossRef
- Wilcox, MH, Hall, J, Pike, H, Templeton, PA, Fawley, WN, Parnell, P, Verity, P (2003) Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect 54: pp. 196-201 CrossRef
- Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey
HSS Journal ®
Volume 10, Issue 1 , pp 45-51
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- prosthetic joint infection
- international survey
- infection prevention strategies
- Industry Sectors
- Author Affiliations
- 1. Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- 2. Department of Orthopedics Clinical Sciences Lund, Lund University, Lund, Sweden
- 3. The Swedish Knee Arthroplasty Register, Lund, Sweden
- 5. National Musculoskeletal Competence Centre, Lund, Sweden
- 4. Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia