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Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey

  • Original Article
  • Published:
HSS Journal ®

Abstract

Background

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.

Questions/Purposes

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.

Results

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.

Conclusion

Current evidence-based guidelines are incomplete and evidence should be updated specifically to address patient needs undergoing TJA.

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References

  1. Adams AL, Paxton EW, Wang JQ, et al. Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg Am. 2013; 95(6): 481-7.

    Article  PubMed  Google Scholar 

  2. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009; 91(1): 128-33.

    Article  PubMed  Google Scholar 

  3. Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010; 468(1): 45-51.

    Article  PubMed  Google Scholar 

  4. Bozic KJ, Lau E, Kurtz S, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am. 2012; 94(9): 794-800.

    PubMed  Google Scholar 

  5. British Orthopaedic Association. Primary total hip replacement: a guide to good practice. London: British Orthopaedic Association; 2006.

    Google Scholar 

  6. Chiu FY, Lin CF, Chen CM, Lo WH, Chaung TY. Cefuroxime-impregnated cement at primary total knee arthroplasty in diabetes mellitus. A prospective, randomized study. J Bone Joint Surg Br. 2001; 83(5): 691-5.

    Article  CAS  PubMed  Google Scholar 

  7. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesaeter LB, Finlayson SR. Cost-effectiveness of antibiotic-impregnated bone cement used in primary total hip arthroplasty. J Bone Joint Surg Am. 2009; 91(3): 634-41.

    Article  PubMed  Google Scholar 

  8. Dale H, Fenstad AM, Hallan G, et al. Increasing risk of prosthetic joint infection after total hip arthroplasty. Acta Orthop. 2012; 83(5): 449-58.

    Article  PubMed  Google Scholar 

  9. Dale H, Hallan G, Espehaug B, Havelin LI, Engesæter LB. Increasing risk of revision due to deep infection after hip Arthroplasty. Acta Orthop. 2009; 80: 6,639-45.

    Article  Google Scholar 

  10. Danish Knee Arthroplasty register. Annual report 2010. Available: http://www.knee.dk/groups/dkr/pdf/DKRreportEnglish2010.pdf. Accessed: 4/21/2013.

  11. Dean NC, Bateman KA, Donnelly SM, Silver MP, Snow GL, Hale D. Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest. 2006; 130(3): 794-9.

    Article  PubMed  Google Scholar 

  12. Espehaug B, Engesaeter LB, Vollset SE, Havelin LI, Langeland N. 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. 1997; 79: 590-595. 1987.

    Article  CAS  PubMed  Google Scholar 

  13. 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.

    Google Scholar 

  14. Gandhi R, Razak F, Pathy R, Davey JR, Syed K, Mahomed NN. Antibiotic bone cement and the incidence of deep infection after total knee arthroplasty. J Arthroplasty. 2009; 24(7): 1015-8.

    Article  PubMed  Google Scholar 

  15. Hepner KA, Rowe M, Rost K, et al. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007; 147(5): 320-9.

    Article  PubMed  Google Scholar 

  16. Hsu C, Cheng SH. Practice guideline adherence and health care outcomes—use of prophylactic antibiotics during surgery in Taiwan. J Eval Clin Pract. 2009; 15(6): 1091-6.

    Article  PubMed  Google Scholar 

  17. Iorio R, Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty. 2012; 27(5): 726-9.e1.

    Article  PubMed  Google Scholar 

  18. Jämsen E, Furnes O, Engesæter LB, et al. Prevention of deep infection in joint replacement surgery a review. Acta Orthop. 2010; 81(6): 660-666.

    Article  PubMed  Google Scholar 

  19. Jämsen E, Nevalainen P, Eskelinen A, Huotari K, Kalliovalkama J, Moilanen T. 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. 2012; 94(14): e101.

    Article  PubMed  Google Scholar 

  20. Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010; 92(9): 1820-6.

    Article  PubMed  Google Scholar 

  21. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4): 780-5.

    Article  PubMed  Google Scholar 

  22. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8): 61-5.e1.

    Article  PubMed  Google Scholar 

  23. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999; 20: 247-280.

    Article  Google Scholar 

  24. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009; 91(7): 1621-9.

    Article  PubMed  Google Scholar 

  25. Merollini KM, Zheng H, Graves N. Most relevant strategies for preventing surgical site infection after total hip arthroplasty: guideline recommendations and expert opinion. Am J Infect Control. 2013; 41(3): 221-6.

    Article  PubMed  Google Scholar 

  26. Merollini KM, Crawford RW, Whitehouse SL, Graves N. Surgical site infection prevention following total hip arthroplasty in Australia: a cost-effectiveness analysis. Am J Infect Control. 2013; 41: 803-809.

    Article  PubMed  Google Scholar 

  27. Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty. 2009; 24(6 Suppl): 44-7.

    Article  PubMed  Google Scholar 

  28. Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg Br. 2012; 94(10): 1330-8.

    Article  CAS  PubMed  Google Scholar 

  29. Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013; 95(9): 775-82.

    Article  PubMed  Google Scholar 

  30. 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.

  31. 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.

  32. 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(6): 1343-8.

    Article  PubMed  Google Scholar 

  33. Schrama JC, Espehaug B, Hallan G, et al. 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). 2010; 62(4): 473-9.

    Article  Google Scholar 

  34. 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.

  35. Tsaras G, Osmon DR, Mabry T, et al. Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted County, Minnesota, 1969–2007. Infect Control Hosp Epidemiol. 2012; 33(12): 1207-12.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Wilcox MH, Hall J, Pike H, et al. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect. 2003; 54(3): 196-201.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

No grant funding was used to support this project. We would like to acknowledge all the International Society of Orthopedic Centers members who participated in the survey.

Disclosures

ᅟ

Conflict of Interest:

Katharina Merollini, PhD, Benjamin F. Ricciardi, MD and Annette W-Dahl, PhD have declared that they have no conflict of interest. Mathias P. Bostrom, MD is a paid consultant to Smith and Nephew, received grant support, is a board member of the Orthopedic Research Society and HSS Journal, outside the work. Lars Lidgren, MD owns stock/stock options in Orthocell and Bone support, is a board member of International Society of Orthopedic Centers (ISOC) and European Bone and Joint Infection Society, outside the work. Jonas Ranstam, MD receives personal fees from Medtronic Inc. for publication committee membership, is a deputy editor for Osteoarthritis Cartilage, and a board member for OARSI, outside the work.

Human/Animal Rights:

This article does not contain any studies with human or animal subjects performed by the any of the authors.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Benjamin F. Ricciardi MD & Mathias P. Bostrom MD

  2. Department of Orthopedics Clinical Sciences Lund, Lund University, Lund, Sweden

    Lars Lidgren MD, Jonas Ranstam MD & Annette W-Dahl PhD

  3. The Swedish Knee Arthroplasty Register, Lund, Sweden

    Lars Lidgren MD & Annette W-Dahl PhD

  4. Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia

    Katharina M. D. Merollini PhD

  5. National Musculoskeletal Competence Centre, Lund, Sweden

    Jonas Ranstam MD

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  1. Benjamin F. Ricciardi MD
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  2. Mathias P. Bostrom MD
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Correspondence to Benjamin F. Ricciardi MD.

Additional information

Level of Evidence: Level I: (Guidelines) and Level V Survey (Expert Consensus). See the Guidelines for Authors for a complete description of levels of evidence.

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Ricciardi, B.F., Bostrom, M.P., Lidgren, L. et al. Prevention of Surgical Site Infection in Total Joint Arthroplasty: An International Tertiary Care Center Survey. HSS Jrnl 10, 45–51 (2014). https://doi.org/10.1007/s11420-013-9369-1

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  • DOI: https://doi.org/10.1007/s11420-013-9369-1

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