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Clinical Orthopaedics and Related Research®

, Volume 471, Issue 7, pp 2383–2399 | Cite as

Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections

  • Antonia F. Chen
  • Charles B. Wessel
  • Nalini RaoEmail author
Survey

Abstract

Background

Staphylococcus aureus is the most common organism responsible for orthopaedic surgical site infections (SSIs). Patients who are carriers for methicillin-sensitive S. aureus or methicillin-resistant S. aureus (MRSA) have a higher likelihood of having invasive S. aureus infections. Although some have advocated screening for S. aureus and decolonizing it is unclear whether these efforts reduce SSIs.

Questions/purposes

The purposes of this study were to determine (1) whether S. aureus screening and decolonization reduce SSIs in orthopaedic patients and (2) if implementing this protocol is cost-effective.

Methods

Studies for this systematic review were identified by searching PubMed, which includes MEDLINE (1946–present), EMBASE.com (1974–present), and the Cochrane Library’s (John Wiley & Sons) Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTAD), and the NHS Economic Evaluation Database (NHSEED). Comprehensive literature searches were developed using EMTREE, MeSH, and keywords for each of the search concepts of decolonization, MRSA, and orthopedics/orthopedic surgery. Studies published before 1968 were excluded. We analyzed 19 studies examining the ability of the decolonization protocol to reduce SSIs and 10 studies detailing the cost-effectiveness of S. aureus screening and decolonization.

Results

All 19 studies showed a reduction in SSIs or wound complications by instituting a S. aureus screening and decolonization protocol in elective orthopaedic (total joints, spine, and sports) and trauma patients. The S. aureus screening and decolonization protocol also saved costs in orthopaedic patients when comparing the costs of screening and decolonization with the reduction of SSIs.

Conclusions

Preoperative screening and decolonization of S. aureus in orthopaedic patients is a cost-effective means to reduce SSIs.

Level of Evidence

Level IV, systematic review of Level I–IV studies. See the Guidelines for Authors for a complete description of levels of evidence.

Keywords

Triclosan Mupirocin Orthopaedic Patient Mupirocin Resistance Intranasal Mupirocin 
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 Melissa Ratajeski MLIS, AHIP, RLAT, for assistance with the bibliographic file management software and Carola Van Eck MD, PhD, for language translation.

References

  1. 1.
    Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009;48:922–930.PubMedCrossRefGoogle Scholar
  2. 2.
    Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, Sloane R, Sexton DJ. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009;4:e8305.PubMedCrossRefGoogle Scholar
  3. 3.
    Bengtsson S, Hambraeus A, Laurell G. Wound infections after surgery in a modern operating suite: clinical, bacteriological and epidemiological findings. J Hyg (Lond). 1979;83:41–57.CrossRefGoogle Scholar
  4. 4.
    Berthelot P, Grattard F, Cazorla C, Passot JP, Fayard JP, Meley R, Bejuy J, Farizon F, Pozzetto B, Lucht F. Is nasal carriage of Staphylococcus aureus the main acquisition pathway for surgical-site infection in orthopaedic surgery? Eur J Clin Microbiol Infect Dis. 2010;29:373–382.PubMedCrossRefGoogle Scholar
  5. 5.
    Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box AT, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362:9–17.PubMedCrossRefGoogle Scholar
  6. 6.
    Caffrey AR, Woodmansee SB, Crandall N, Tibert C, Fielding C, Mikolich DJ, Vezeridis MP, LaPlante KL. Low adherence to outpatient preoperative methicillin-resistant Staphylococcus aureus decolonization therapy. Infect Control Hosp Epidemiol. 2011;32:930–932.PubMedCrossRefGoogle Scholar
  7. 7.
    Chen AF, Chivukula S, Jacobs LJ, Tetreault MW, Lee JY. What is the prevalence of MRSA colonization in elective spine cases? Clin Orthop Relat Res. 2012;470:2684–2689.PubMedCrossRefGoogle Scholar
  8. 8.
    Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281–286.PubMedCrossRefGoogle Scholar
  9. 9.
    Coskun D, Aytac J. Decrease in Staphylococcus aureus surgical-site infection rates after orthopaedic surgery after intranasal mupirocin ointment. J Hosp Infect. 2004;58:90–91.PubMedCrossRefGoogle Scholar
  10. 10.
    Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SR. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol. 2012;33:152–159.PubMedCrossRefGoogle Scholar
  11. 11.
    De Lucas-Villarrubia JC, Lopez-Franco M, Granizo JJ, De Lucas-Garcia JC, Gomez-Barrena E. Strategy to control methicillin-resistant Staphylococcus aureus post-operative infection in orthopaedic surgery. Int Orthop. 2004;28:16–20.PubMedCrossRefGoogle Scholar
  12. 12.
    Edmundson SP, Hirpara KM, Bennett D. The effectiveness of methicillin-resistant Staphylococcus aureus colonisation screening in asymptomatic healthcare workers in an Irish orthopaedic unit. Eur J Clin Microbiol Infect Dis. 2011;30:1063–1066.PubMedCrossRefGoogle Scholar
  13. 13.
    Engemann JJ, Carmeli Y, Cosgrove SE, Fowler VG, Bronstein MZ, Trivette SL, Briggs JP, Sexton DJ, Kaye KS. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. 2003;36:592–598.PubMedCrossRefGoogle Scholar
  14. 14.
    Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res. 2011;469:945–953.PubMedCrossRefGoogle Scholar
  15. 15.
    Forward KR. The value of multiple surveillance cultures for methicillin-resistant Staphylococcus aureus. Am J Infect Control. 2010;38:596–599.PubMedCrossRefGoogle Scholar
  16. 16.
    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.PubMedCrossRefGoogle Scholar
  17. 17.
    Graber CJ, Schwartz BS. Failure of decolonization in patients with infections due to mupirocin-resistant strains of community-associated methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2008;29:284; author reply 284–285.PubMedCrossRefGoogle Scholar
  18. 18.
    Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res. 2010;159:503–508.PubMedCrossRefGoogle Scholar
  19. 19.
    Hacek DM, Robb WJ, Paule SM, Kudrna JC, Stamos VP, Peterson LR. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res. 2008;466:1349–1355.PubMedCrossRefGoogle Scholar
  20. 20.
    Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.PubMedCrossRefGoogle Scholar
  21. 21.
    Harrop JS, Styliaras JC, Ooi YC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20:94–101.PubMedCrossRefGoogle Scholar
  22. 22.
    Hassan K, Koh C, Karunaratne D, Hughes C, Giles SN. Financial implications of plans to combat methicillin-resistant Staphylococcus aureus (MRSA) in an orthopaedic department. Ann R Coll Surg Engl. 2007;89:668–671.PubMedCrossRefGoogle Scholar
  23. 23.
    Johnston P, Norrish AR, Brammar T, Walton N, Hegarty TA, Coleman NP. Reducing methicillin-resistant Staphylococcus aureus (MRSA) patient exposure by infection control measures. Ann R Coll Surg Engl. 2005;87:123–125.PubMedCrossRefGoogle Scholar
  24. 24.
    Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol. 2005;26:916–922.PubMedCrossRefGoogle Scholar
  25. 25.
    Kalmeijer MD, Coertjens H, De Baere GA, Stuurman A, Van Belkum A, Kluytmans JA. Postoperative wound infections in orthopedic surgery: the effect of mupirocine nasal ointment. Pharmaceutisch Weekblad. 2001;136:730–731.Google Scholar
  26. 26.
    Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, 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
  27. 27.
    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
  28. 28.
    Kaminski A, Kammler J, Wick M, Muhr G, Kutscha-Lissberg F. Transmission of methicillin-resistant Staphylococcus aureus among hospital staff in a German trauma centre: a problem without a current solution? J Bone Joint Surg Br. 2007;89:642–645.PubMedGoogle Scholar
  29. 29.
    Kelly JC, O’Briain DE, Walls R, Lee SI, O’Rourke A, Mc Cabe JP. The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients. Surgeon. 2012;10:75–79.PubMedCrossRefGoogle Scholar
  30. 30.
    Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, Hunter DJ, Martha JF, Miley GB, Parazin SJ, Dejoie P, Richmond JC. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92:1820–1826.PubMedCrossRefGoogle Scholar
  31. 31.
    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
  32. 32.
    Lauderdale KJ, Malone CL, Boles BR, Morcuende J, Horswill AR. Biofilm dispersal of community-associated methicillin-resistant Staphylococcus aureus on orthopedic implant material. J Orthop Res. 2010;28:55–61.PubMedGoogle Scholar
  33. 33.
    Lautenbach E, Nachamkin I, Hu B, Fishman NO, Tolomeo P, Prasad P, Bilker WB, Zaoutis TE. Surveillance cultures for detection of methicillin-resistant Staphylococcus aureus: diagnostic yield of anatomic sites and comparison of provider- and patient-collected samples. Infect Control Hosp Epidemiol. 2009;30:380–382.PubMedCrossRefGoogle Scholar
  34. 34.
    Lee BY, Wiringa AE, Bailey RR, Goyal V, Tsui B, Lewis GJ, Muder RR, Harrison LM. The economic effect of screening orthopedic surgery patients preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2010;31:1130–1138.PubMedCrossRefGoogle Scholar
  35. 35.
    Luna CM, Boyeras Navarro ID. Management of methicillin-resistant Staphylococcus aureus pneumonia. Curr Opin Infect Dis. 2010;23:178–184.PubMedCrossRefGoogle Scholar
  36. 36.
    Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br. 2006;88:812–817.PubMedGoogle Scholar
  37. 37.
    Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J, Hedblom EC, Jacobson C, Smulders M, Gemmen E, Bharmal M. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998–2003). Clin Infect Dis. 2007;45:1132–1140.PubMedCrossRefGoogle Scholar
  38. 38.
    Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980–985.PubMedCrossRefGoogle Scholar
  39. 39.
    Patel N, Bagan B, Vadera S, Maltenfort MG, Deutsch H, Vaccaro AR, Harrop J, Sharan A, Ratliff JK. Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine. 2007;6:291–297.PubMedCrossRefGoogle Scholar
  40. 40.
    Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg. 2009;208:981–986; discussion 986–988.PubMedCrossRefGoogle Scholar
  41. 41.
    Portigliatti Barbos M, Mognetti B, Pecoraro S, Picco W, Veglio V. Decolonization of orthopedic surgical team S. aureus carriers: impact on surgical-site infections. J Orthop Traumatol. 2010;11:47–49.PubMedCrossRefGoogle Scholar
  42. 42.
    Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R 3rd. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466:1343–1348.PubMedCrossRefGoogle Scholar
  43. 43.
    Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL 3rd, Hamilton CW. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26:1501–1507.PubMedCrossRefGoogle Scholar
  44. 44.
    Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol. 2000;21:510–515.PubMedCrossRefGoogle Scholar
  45. 45.
    Ro K. Methicillin-resistant Staphylococcus aureus colonization: a review of the literature on prevention and eradication. Advanced Emergency Nursing Journal. 2008;30(4):344–356.Google Scholar
  46. 46.
    Rohr U, Wilhelm M, Muhr G, Gatermann S. Qualitative and (semi)quantitative characterization of nasal and skin methicillin-resistant Staphylococcus aureus carriage of hospitalized patients. Int J Hyg Environ Health. 2004;207:51–55.PubMedCrossRefGoogle Scholar
  47. 47.
    Sankar B, Hopgood P, Bell KM. The role of MRSA screening in joint-replacement surgery. Int Orthop. 2005;29:160–163.PubMedCrossRefGoogle Scholar
  48. 48.
    Slover J, Haas JP, Quirno M, Phillips MS, Bosco JA 3rd. Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients. J Arthroplasty. 2011;26:360–365.PubMedCrossRefGoogle Scholar
  49. 49.
    Sott AH, Jones R, Davies S, Cumberland N. The value of pre-operative screening for MRSA in the reduction of sepsis in total hip replacement associated with MRSA: a prospective audit. Hip Int. 2001;11:102–106.Google Scholar
  50. 50.
    Tacconelli E, De Angelis G. Pneumonia due to methicillin-resistant Staphylococcus aureus: clinical features, diagnosis and management. Curr Opin Pulm Med. 2009;15:218–222.PubMedCrossRefGoogle Scholar
  51. 51.
    van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;4:CD006216.PubMedGoogle Scholar
  52. 52.
    van Rijen MM, Bode LG, Baak DA, Kluytmans JA, Vos MC. Reduced costs for staphylococcus aureus carriers treated prophylactically with mupirocin and chlorhexidine in cardiothoracic and orthopaedic surgery. PloS One. 2012;7:e43065.PubMedCrossRefGoogle Scholar
  53. 53.
    Vincent JL. Nosocomial infections in adult intensive-care units. Lancet. 2003;361:2068–2077.PubMedCrossRefGoogle Scholar
  54. 54.
    von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344:11–16.CrossRefGoogle Scholar
  55. 55.
    Wassenberg MW, de Wit GA, Bonten MJ. Cost-effectiveness of preoperative screening and eradication of staphylococcus aureus carriage. PloS One. 2011;6:e14815.PubMedCrossRefGoogle Scholar
  56. 56.
    Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, Nouwen JL. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;5:751–762.PubMedCrossRefGoogle Scholar
  57. 57.
    Wilcox MH, Hall J, Pike H, Templeton PA, Fawley WN, Parnell P, Verity P. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect. 2003;54:196–201.PubMedCrossRefGoogle Scholar
  58. 58.
    Wilczynski NL, Haynes RB, Lavis JN, Ramkissoonsingh R, Arnold-Oatley AE, HSR Hedges team. Optimal search strategies for detecting health services research studies in MEDLINE. CMAJ. 2004;171:1179–1185.PubMedGoogle Scholar
  59. 59.
    Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. J Spinal Disord. 1998;11:124–128.PubMedGoogle Scholar
  60. 60.
    Zoabi M, Keness Y, Titler N, Bisharat N. Compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and its impact on rates of nosocomial MRSA bacteremia. Isr Med Assoc J. 2011;13:740–744.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Antonia F. Chen
    • 1
  • Charles B. Wessel
    • 2
  • Nalini Rao
    • 3
    Email author
  1. 1.Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA
  2. 2.University of Pittsburgh Health Sciences Library SystemUniversity of PittsburghPittsburghUSA
  3. 3.Department of Medicine and Orthopaedic Surgery, Division of Infectious DiseaseUniversity of Pittsburgh School of MedicinePittsburghUSA

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