Advertisement

Clinical Orthopaedics and Related Research

, Volume 466, Issue 6, pp 1343–1348 | Cite as

A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections

  • Nalini Rao
  • Barbara Cannella
  • Lawrence S. Crossett
  • A. J. YatesJr
  • Richard McGoughIII
Symposium: Papers Presented at the 2007 Meeting of the Musculoskeletal Infection Society

Abstract

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.

Keywords

Total Knee Arthroplasty Total Joint Arthroplasty Mupirocin Nasal Carrier Preoperative Screening 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

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.

References

  1. 1.
    Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol. 1990;11:89–93.PubMedCrossRefGoogle Scholar
  2. 2.
    Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Ann Thorac Surg. 2001;71:1572–1578; discussion 1578–1579.PubMedCrossRefGoogle Scholar
  3. 3.
    D’Souza HA, Baron EJ. BBL CHROMagar Staph aureus is superior to mannitol salt for detection of Staphylococcus aureus in complex mixed infections. Am J Clin Pathol. 2005;123:806–808.PubMedCrossRefGoogle Scholar
  4. 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
  5. 5.
    Gernaat-van der Sluis AJ, Hoogenboom-Verdegaal AM, Edixhoven PJ, Spies-van Rooijen NH. Prophylactic mupirocin could reduce orthopedic wound infections. 1,044 patients treated with mupirocin compared with 1,260 historical controls. Acta Orthop Scand. 1998;69:412–414.CrossRefGoogle Scholar
  6. 6.
    Hervey SL, Purves HR, Guller U, Toth AP, Vail TP, Pietrobon R. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-Nationwide Inpatient Sample. J Bone Joint Surg Am. 2003;85:1775–1783.PubMedGoogle Scholar
  7. 7.
    Herwaldt LA. Reduction of Staphylococcus aureus nasal carriage, infection in dialysis patients. J Hosp Infect. 1998;40 Suppl B:S13–23.PubMedCrossRefGoogle Scholar
  8. 8.
    Irizarry L, Rupp J, Griffith J. Frequency of high-level mupirocin-resistant Staphylococcus aureus in a tertiary care facility. Antimicrob Agents Chemother. 1996;40:1967–1968.PubMedGoogle Scholar
  9. 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
  10. 10.
    Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol. 2000;21:319–323.PubMedCrossRefGoogle Scholar
  11. 11.
    Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10:505–520.PubMedGoogle Scholar
  12. 12.
    Kluytmans JA, Manders MJ, van Bommel E, Verbrugh H. Elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients. Infect Control Hosp Epidemiol. 1996;17:793–797.PubMedGoogle Scholar
  13. 13.
    Kluytmans JA, Mouton JW, VandenBergh MF, Manders MJ, Maat AP, Wagenvoort JH, Michel MF, Verbrugh HA. Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol. 1996;17:780–785.PubMedCrossRefGoogle Scholar
  14. 14.
    Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64:162–168.PubMedCrossRefGoogle Scholar
  15. 15.
    Leski TA, Gniadkowski M, Skoczynska A, Stefaniuk E, Trzcinski K, Hryniewicz W. Outbreak of mupirocin-resistant staphylococci in a hospital in Warsaw, Poland, due to plasmid transmission and clonal spread of several strains. J Clin Microbiol. 1999;37:2781–2788.PubMedGoogle Scholar
  16. 16.
    Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2003;85:27–32.PubMedGoogle Scholar
  17. 17.
    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250–278; quiz 279–280.PubMedCrossRefGoogle Scholar
  18. 18.
    Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol. 1996;17:811–813.PubMedGoogle Scholar
  19. 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
  20. 20.
    Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134:S10–17.PubMedCrossRefGoogle Scholar
  21. 21.
    Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, Pfaller MA, Sheppard D, Twombley J, French PP, Herwaldt LA. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346:1871–1877.PubMedCrossRefGoogle Scholar
  22. 22.
    Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother. 1998;32:S7–16.PubMedGoogle Scholar
  23. 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
  24. 24.
    Sculco TP. The economic impact of infected total joint arthroplasty. Instr Course Lect. 1993;42:349–351.PubMedGoogle Scholar
  25. 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
  26. 26.
    Suzuki Y, Kamigaki T, Fujino Y, Tominaga M, Ku Y, Kuroda Y. Randomized clinical trial of preoperative intranasal mupirocin to reduce surgical-site infection after digestive surgery. Br J Surg. 2003;90:1072–1075.PubMedCrossRefGoogle Scholar
  27. 27.
    Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis. 2003;37:1629–1638.PubMedCrossRefGoogle Scholar
  28. 28.
    Upton A, Lang S, Heffernan H. Mupirocin and Staphylococcus aureus: a recent paradigm of emerging antibiotic resistance. J Antimicrob Chemother. 2003;51:613–617.PubMedCrossRefGoogle Scholar
  29. 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. 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
  31. 31.
    Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hosp Infect. 1995;31:13–24.PubMedCrossRefGoogle Scholar
  32. 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

Copyright information

© The Association of Bone and Joint Surgeons 2008

Authors and Affiliations

  • Nalini Rao
    • 1
  • Barbara Cannella
    • 1
  • Lawrence S. Crossett
    • 2
  • A. J. YatesJr
    • 2
  • Richard McGoughIII
    • 2
  1. 1.Division of Infectious Disease, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Department of Orthopaedic SurgeryUniversity of Pittsburgh Medical CenterPittsburghUSA

Personalised recommendations