A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections
- 1k Downloads
Staphylococcus aureus (S. aureus) is an independent risk factor for orthopaedic surgical site infection (SSI). To determine whether a preoperative decolonization protocol reduces S. aureus SSIs, we conducted a prospective observational study of patients undergoing elective total joint arthroplasty (TJA) at our institution, with two control groups. The concurrent control group comprised patients of surgeons who did not participate in the intervention study. The preintervention control group comprised patients of participating surgeons who had undergone elective TJA during the year before the study. Patients in the intervention group were screened preoperatively for S. aureus by nasal swab cultures. S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine bath once daily for 5 days before surgery. All 164 of 636 participants (26%) who tested positive completed the decolonization protocol without adverse events and had no postoperative S. aureus SSIs at 1-year followup. In contrast, 1330 concurrent control patients had 12 S. aureus infections. If these infections had occurred in the 26% of patients expected to be nasal carriers of S. aureus at a given time, the infection rate would have been 3.5% (12 of 345) in the control group. In addition, the overall infection rate of the participating surgeons, including nonstaphylococcal infections, decreased from 2.6% during the preintervention period to 1.5% during the intervention period, translating to an adjusted economic gain of $231,741 for the hospital. The data suggest a preoperative decolonization protocol reduces S. aureus SSIs in patients undergoing TJA.
Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
KeywordsTotal Knee Arthroplasty Total Joint Arthroplasty Mupirocin Nasal Carrier Preoperative Screening
We thank James A. Schnebel for his help with this study.We thank Cindy Hamilton and Anne Derbes for editing the manuscript. We thank James A. Schnebel for processing nasal swabs for recovery and confirmation of MSSA and MRSA.
- 4.Flayhart D, Hindler JF, Bruckner DA, Hall G, Shrestha RK, Vogel SA, Richter SS, Howard W, Walther R, Carroll KC. Multicenter evaluation of BBL CHROMagar MRSA medium for direct detection of methicillin-resistant Staphylococcus aureus from surveillance cultures of the anterior nares. J Clin Microbiol. 2005;43:5536–5540.PubMedCrossRefGoogle Scholar
- 9.Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, van Belkum A, Kluytmans JA. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35:353–358.PubMedCrossRefGoogle Scholar
- 19.National Nosocomial Infections Surveillance (NNIS) System report, data summary from October 1986-April 1998, issued June 1998. Am J Infect Control. 1998;26:522–533.Google Scholar
- 23.Sandri AM, Dalarosa MG, Ruschel de Alcantara L, da Silva Elias L, Zavascki AP. Reduction in incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in an intensive care unit: role of treatment with mupirocin ointment and chlorhexidine baths for nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27:185–187.PubMedCrossRefGoogle Scholar
- 25.Simor AE, Phillips E, McGeer A, Konvalinka A, Loeb M, Devlin HR, Kiss A. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44:178–185.PubMedCrossRefGoogle Scholar
- 29.Watanakunakorn C, Brandt J, Durkin P, Santore S, Bota B, Stahl CJ. The efficacy of mupirocin ointment and chlorhexidine body scrubs in the eradication of nasal carriage of Staphylococcus aureus among patients undergoing long-term hemodialysis. Am J Infect Control. 1992;20:138–141.PubMedCrossRefGoogle Scholar
- 30.Wendt C, Schinke S, Wurttemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007;28:1036–1043.PubMedCrossRefGoogle Scholar
- 32.Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23:183–189.PubMedCrossRefGoogle Scholar