Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery

The prevention of infection: 12 modifiable risk factors

AIMS

Prosthetic joint infection (PJI) remains a serious complication that is associated with high morbidity and costs. The aim of this study was to prepare a systematic review to examine patient-related and perioperative risk factors that can be modified in an attempt to reduce the rate of PJI.

MATERIALS AND METHODS

A search of PubMed and MEDLINE was conducted for articles published between January 1990 and February 2018 with a combination of search terms to identify studies that dealt with modifiable risk factors for reducing the rate of PJI. An evidence-based review was performed on 12 specific risk factors: glycaemic control, obesity, malnutrition, smoking, vitamin D levels, preoperative Staphylococcus aureus screening, the management of anti-rheumatic medication, perioperative antibiotic prophylaxis, presurgical skin preparation, the operating room environment, irrigant options, and anticoagulation.

RESULTS

Poor glycaemic control, obesity, malnutrition, and smoking are all associated with increased rates of PJI. Vitamin D replacement has been shown in preliminary animal studies to decrease rates of PJI. Preoperative Staphylococcus aureus screening and appropriate treatment results in decreased rates of PJI. Perioperative variables, such as timely and appropriate dosage of prophylactic antibiotics, skin preparation with chlorohexidine-based solution, and irrigation with dilute betadine at the conclusion of the operation, have all been associated with reduced rates of PJI. Similarly, aggressive anticoagulation and increased operating room traffic should be avoided to help minimize risk of PJI.

CONCLUSION

PJI remains a serious complication of arthroplasty. Surgeons should be vigilant of the modifiable risk factors that can be addressed in an attempt to reduce the risk of PJI.

Surgical Site Infections in Spine Surgery: Preoperative Prevention Strategies to Minimize Risk

STUDY DESIGN

Literature review.

OBJECTIVES

A review of the literature identifying preoperative risk factors for developing surgical site infections after spine surgery and discussion of the preventive strategies to minimize risks.

METHODS

A review of the literature and synthesis of the data to provide an updated review on the preoperative management of surgical site infection.

RESULTS

Preoperative prevention strategies of reducing surgical site infections in spine surgery remains a challenging problem. Careful mitigation of modifiable patient comorbidities, blood glucose control, smoking, obesity, and screening for pathologic microorganisms is paramount to reduce this risk. Individualized antibiotic regimens, skin preparation, and hand hygiene also play a critical role in surgical site infection prevention.

CONCLUSIONS

This review of the literature discusses the preoperative preventive strategies and risk management techniques of surgical site infections in spine surgery. Significant decreases in surgical site infections after spine surgery have been noted over the past decade due to increased awareness and implementation of the prevention strategies described in this article. However, it is important to recognize that prevention of surgical site infection requires a system-wide approach that includes the hospital system, the surgeon, and the patient. Continued efforts should focus on system-wide implementation programs including careful patient selection, individualized antibiotic treatment algorithms, identification of pathologic organisms, and preoperative decolonization programs to further prevent surgical site infections and optimize patient outcomes.

Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI.

RECENT FINDINGS

Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.

Cost Efficacy of Methicillin-Resistant Staphylococcus aureus Decolonization With Intranasal Povidone-Iodine

BACKGROUND

With increasing rates of virulent drug resistant organisms, MRSA (methicillin-resistant Staphylococcus aureus) decolonization has been demonstrated to decrease infection rates. Recent research has shown the antiseptic povidone-iodine to be equally effective and potentially cost saving compared to intranasal mupirocin. This study's purpose is to evaluate the incidence of MRSA colonization in a more rural community-based population, rates of infection on a mupirocin decolonization protocol, and develop a cost analysis model to compare costs of utilizing povidone-iodine.

METHODS

Utilizing over 4 years of data, the incidence of MRSA decolonization of consecutive total knee and hip arthroplasties, as well as the rates of infection of patients uncolonized, colonized with successful decolonization, and unsuccessful decolonization were evaluated. Utilizing these data, cost data, and known infection rate utilizing povidone-iodine decolonization, a cost analysis model was developed.

RESULTS

Of the 5584 cases with MRSA data at a single institution, only 3.5% tested positive for intranasal MRSA. Of those patients, 69% were successfully decolonized. Of the 3864 cases with infection data, 21 sustained a surgical site infection within 90 days (0.54%). Of these patients, all tested negative for intranasal MRSA initially and therefore did not undergo the decolonization protocol. The cost analysis predicts a potential savings of $74.72 per patient at our institution to use a global intranasal povidone-iodine protocol prior to total joint arthroplasty.

CONCLUSION

Even with a lower incidence of MRSA than typically reported, utilization of intranasal povidone-iodine would potentially save $74.42 per patient.

Risk Factors for Staphylococcus aureus Nasal Colonization in Joint Arthroplasty Patients

BACKGROUND

Several studies have shown that Staphylococcus aureus (S aureus) nasal colonization is associated with surgical site infection and that preoperative decolonization can reduce infection rates. Up to 30% of joint arthroplasty patients have positive S aureus nasal swabs. Patient risk factors for colonization remain largely unknown. The aim of this study was to determine whether there is a specific patient population at increased risk of S aureus nasal colonization.

METHODS

This study is a retrospective review of 716 patients undergoing hip or knee arthroplasty beginning in 2011. All patients were screened preoperatively for nasal colonization. Univariate and multivariate analyses were used to assess risk factors for nasal colonization.

RESULTS

A total of 716 patients undergoing joint arthroplasty had preoperative nasal screening. One hundred twenty-five (17.50%) nasal swabs were positive for methicillin-susceptible S aureus (MSSA), 13 (1.80%) were positive for methicillin-resistant S aureus (MRSA), and 84 (11.70%) were positive for other organisms. In bivariate analysis, diabetes (P = .04), renal insufficiency (P = .03), and immunosuppression (P = .02) were predictors of nasal colonization with MSSA/MRSA. In multivariate analysis, immunosuppression (P = .04; odds ratio, 2.0; 95% confidence interval, 1.03-3.71) and renal insufficiency (P = .04; odds ratio, 2.5; 95% confidence interval, 1.01-6.18) were independent predictors of nasal colonization with MSSA/MRSA.

CONCLUSION

Overall, 17.5% of patients undergoing primary hip or knee arthroplasty screened positive for S aureus. Diabetes, renal insufficiency, and immunosuppression are risk factors for such colonization. Given that these comorbidities are already known independent risk factors for periprosthetic joint infection, these patients should be particularly screened and when necessary, decolonized.

Control of healthcare- and community-associated MRSA: recent progress and persisting challenges

BACKGROUND

Healthcare adapted meticillin-resistant Staphylococcus aureus (MRSA) has spread to hospitals around the world over 50 years. More recently, other strains of MRSA have emerged with the ability to spread in the community and infect otherwise healthy individuals. Morbidity and mortality associated with MRSA remains high and its control in both the healthcare and community setting has proven challenging.

SOURCES OF DATA

Pubmed (Medline).

AREAS OF AGREEMENT

The use of targeted screening and decolonization, hand hygiene and antimicrobial stewardship is supported by the most robust studies, though many studies have implemented bundles for effective healthcare-associated (HA)-MRSA control.

AREAS OF CONTENTION

Universal screening, universal decolonization and contact precautions for HA-MRSA control are supported by less evidence. Some interventions may not be cost-effective. Contact precautions may be associated with potential for patient harm. Evidence for effective control community acquired (CA)-MRSA is largely lacking.

GROWING POINTS

Programmes that focus on implementing bundles of interventions aimed at targeting HA-MRSA are more likely to be effective, with an emphasis on hand hygiene as a key component. Control of CA-MRSA is likely to be more difficult to achieve and relies on prevalence, risk factors and community healthcare interactions on a broader scale.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research in the area of CA-MRSA in particular is required. Antimicrobial stewardship for both CA and HA-MRSA is promising, as is the role of whole genome sequencing in characterizing transmission. However, further work is required to assess their long-term roles in controlling MRSA. With many institutions applying widespread use of chlorhexidine washes, monitoring for chlorhexidine resistance is paramount to sustaining efforts at controlling MRSA.

Multifaceted aseptic protocol decreases surgical site infections following hip arthroplasty

INTRODUCTION

We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after hip arthroplasty in a single medical centre with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

A prospectively collected database of all patients undergoing hip arthroplasty in a single centre between 2005 and 2011 was reviewed for SSI using Centers for Disease Control (CDC) criteria and AAOS guidelines. All patients were administered an aseptic protocol consisting of: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical-site wipes; modified instrument care; perioperative prophylactic vancomycin and cefazolin; and surgical-site skin preparation with chlorhexidine, alcohol and iodophor. We compare our protocol hip arthroplasty SSI rate to our institutional historical control and to contemporary literature.

RESULTS

Among 774 patients, 69% were ASA>2, 45% had BMI≥30 and 10.3% had rheumatoid arthritis. We found an overall 0.39% infection rate; significantly lower than our institutional historical control (0.39% vs. 2.60%, p<0.001, OR 0.15, NNT 200) and significantly lower than 6 published reports (p<0.001-0.022, OR 0.16-0.22). Compared to these cohorts, significantly more of our patients were ASA>2, had BMI≥30 or had rheumatoid arthritis. Patients with 3 or more identifiable risk factors were at an increased risk of SSI compared to those with 2 or fewer risk factors.

CONCLUSIONS

Our aseptic protocol decreases SSI in a high-risk population undergoing hip arthroplasty in a medical centre and community with a high prevalence of MRSA.

Screening of methicillin-resistant Staphylococcus aureus nasal colonization among elective surgery patients in referral hospital in Indonesia

OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) colonization is associated with serious surgical site infection in high-risk patients. High prevalence of MRSA colonization was reported in many settings, nonetheless local data is required. The purpose of this study is to identify the prevalence and risk factor of MRSA nasal carriage in adult patients in National Referral Hospital in Indonesia before underwent elective surgical procedure.

RESULTS

From 384 patients, 16.9% patients of them had undergone orthopaedic surgery, 51.3% had received antibiotics within the previous 3-month and 41.1% patients had history of hospitalization within the previous 1 year. Total of 21.6% patients were on invasive devices for at least 48 h before the operation; 24.2% had an open wound; 19.3% patients were referred from other hospital/ward. Of these patients, solid tumor without metastasis was the most common factor identified by the Charlson index (38.3%). Nasal colonization of Gram-positive bacteria was detected in 76.8%; S. aureus in 15.6% of patients (n = 60). MRSA was identified in three isolates (0.8%) by both culture and polymerase chain reaction (PCR) tests. Due to low prevalence of MRSA nasal carriage, this finding supports the recommendation to not routinely apply mupirocin for nasal decolonization on patient planned for surgery in Indonesia.

Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.

Effectiveness of preoperative decolonization with nasal povidone iodine in Chinese patients undergoing elective orthopedic surgery: a prospective cross-sectional study

Staphylococcus aureus colonization in the nares of patients undergoing elective orthopedic surgery increases the potential risk of surgical site infections. Methicillin-resistant S. aureus (MRSA) has gained recognition as a pathogen that is no longer only just a hospital-acquired pathogen. Patients positive for MRSA are associated with higher rates of morbidity and mortality following infection. MRSA is commonly found in the nares, and methicillin-sensitive S. aureus (MSSA) is even more prevalent. Recently, studies have determined that screening for this pathogen prior to surgery and diminishing staphylococcal infections at the surgical site will dramatically reduce surgical site infections. A nasal mupirocin treatment is shown to significantly reduce the colonization of the pathogen. However, this treatment is expensive and is currently not available in China. Thus, in this study, we first sought to determine the prevalence of MSSA/MSRA in patients undergoing elective orthopedic surgery in northern China, and then, we treated the positive patients with a nasal povidone-iodine swab. Here, we demonstrate a successful reduction in the colonization of S. aureus. We propose that this treatment could serve as a cost-effective means of eradicating this pathogen in patients undergoing elective orthopedic surgery, which might reduce the rate of surgical site infections.

Sports-specific differences in postsurgical infections after arthroscopically assisted anterior cruciate ligament reconstruction

PURPOSE

Post-operative infection after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a rare but severe complication, particularly for young and active patients. It is unclear whether the prevalence of knee infection is correlated with the type of sports or the level of performance.

METHODS

From 2008 to 2012, the internal single-centre ACL registry of the FIFA Medical Centre of Excellence Regensburg was retrospectively screened for sex, age, time between isolated primary ACL rupture and surgery, surgical technique, rate of infection after ACL reconstruction and the type of sports practised.

RESULTS

In total, 4801 ACL reconstructions had been conducted over 5 years, 4579 in amateur and 221 in professional athletes. After application of the exclusion criteria, 1809 athletes with ACL reconstruction were analysed regarding postsurgical infection and the type of sports practised. Professionals and amateurs did not significantly differ with regard to infection rates (n.s.) but in the timing of ACL repair (p < 0.001). Eleven of 1130 football players had developed postsurgical infection after ACL reconstruction (1.0%) in contrast to 557 skiers and snowboarders without infection (p = 0.02). The timing of ACL repair did not differ between the different types of sports (n.s.). Staphylococcus aureus and epidermidis were the predominant detected bacteria. All patients were hospitalised and successfully treated with arthroscopic lavage and antibiotic medication.

CONCLUSION

ACL infections showed sports-related differences. Athletes practising summer outdoor sports such as football had a significantly higher risk of infection after ACL reconstruction than winter sports athletes. No difference was found between professional and amateur athletes. Relevant prevention strategies for postsurgical ACL infections should consider influencing patient factors such as the type of sports activity and attendant circumstances.

LEVEL OF EVIDENCE

III.

Risk of Surgical Site Infection in Elective Hip and Knee Replacements After Confirmed Eradication of MRSA in Chronic Carriers

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is globally endemic and is a leading cause of surgical site infection (SSI). The purpose of this study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip or knee arthroplasty, who had confirmed eradication and to compare it with incidence of SSI in non-MRSA carriers.

METHODS

This is a retrospective analysis of 6613 patients who underwent elective total hip arthroplasty (THA; n = 3347) and total knee arthroplasty (TKA; n = 3266) at our institution. A cohort of patients who were preoperatively colonized with MRSA was identified. We compared the infection rates with non-MRSA carriers.

RESULTS

We had a colonization rate of 1.3% (83 patients). A total of 79 patients had confirmed eradication of carrier status before surgical intervention. Of these, 38 were THAs and 41 were TKAs. Five of 79 patients (6.32%; 95% confidence interval [CI]: 2.35%-14.79%) had "deep SSI" within 1 year of surgery. There were 2 MRSA infections in THAs (relative risk 4.46; 95% CI: 1.12-17.82). There were 2 MRSA and 1 methicillin-sensitive Staphylococcus aureus infections in TKAs (relative risk 5.61; 95% CI: 1.81-17.38). A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% in THAs and 1.3% in TKAs over the same period.

CONCLUSION

In spite of a selective treatment program for carriers and confirmed eradication, there is still a significantly increased risk of SSI in MRSA-colonized patients undergoing hip or knee arthroplasties.

Can preoperative nasal cultures of Staphylococcus aureus predict infectious complications or outcomes following repair of fracture nonunion?

INTRODUCTION

Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery.

METHODS

Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion.

RESULTS

Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups.

CONCLUSIONS

Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.

Prevention of Surgical Site Infection in Spine Surgery

BACKGROUND

Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures.

OBJECTIVE

To provide a narrative review of practical solutions to reduce SSI in spine surgery.

METHODS

Literature review and synthesis to identify methods that can be used to prevent SSI.

RESULTS

SSI prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. Screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. Preoperative warming of patients and timely administration of antibiotics are critical to prevent SSI. Skin preparation using chlorhexidine and alcohol solutions are recommended. Meticulous surgical technique and maintenance of sterile techniques should always be performed. Postoperatively, traditional methods of tissue oxygenation and glycemic control remain essential. Newer wound care methods such as silver impregnation dressing and wound-assisted vacuum dressing are encouraging but need further investigation.

CONCLUSION

Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI.

Readmission due to infection following total hip and total knee procedures: A retrospective study

Policymakers have expanded readmissions penalty programs to include elective arthroplasties, but little is known about the risk factors for readmissions following these procedures. We hypothesized that infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA) lead to excess readmissions and increased costs. This study aims to evaluate the proportion of readmissions due to infections following THA and TKA.Healthcare Cost and Utilization Project-State Inpatient Databases were used for the study. Procedure codes "8151" and "8154" were used to identify inpatient discharges with THA and TKA in Florida (FL) 2009 to 2013, Massachusetts (MA) 2010 to 2012, and California (CA) 2009 to 2011. Readmission was measured by a Centers for Medicare and Medicaid Services (CMS) validated algorithm. Infections were identified by ICD-9-CM codes: 99859, 99666, 6826, 0389, 486, 4821, 00845, 5990, 48242, 04111, 04112, 04119, 0417, 99591, and 99592. Descriptive analysis was performed.In CA, 4.29% of patients were readmitted with 33.02% of the total readmissions for infection. In FL, 4.7% of patients were readmitted with 33.39% of the readmissions for infection. In MA, 3.92% of patients were readmitted with 35.2% of readmissions for infection. Of the total number of readmissions due to infection, methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) together accounted for 14.88% in CA, 13.38% in FL, and 13.11% in MA.The rate of infection is similar across all 3 states and is a leading cause for readmission following THA and TKA. Programs to reduce the likelihood of MRSA or MSSA infection would reduce readmissions due to infection.

Povidone-Iodine-Based Solutions for Decolonization of Nasal Staphylococcus aureus: A Randomized, Prospective, Placebo-Controlled Study

BACKGROUND

Nasal Staphylococcus aureus decolonization reduces the risk of surgical site infections after orthopedic procedures. Povidone-iodine (PI)-based solutions have shown promising results in bacteria decolonization. The unique physiology of the nose may pose challenges for the bioactivity profiles of PI solutions. This study compared the antibacterial efficacy of an off-the-shelf PI product with a specifically manufactured PI-based skin and nasal antiseptic (SNA).

METHODS

This randomized, placebo-controlled study was conducted at a single institution between April 2014 and July 2015. Four hundred and twenty-nine patients undergoing primary or revision total joint arthroplasty, femoroacetabular osteoplasty, pelvic osteotomy, or total shoulder arthroplasty were included. 10% off-the-shelf PI, 5% PI-based SNA, or saline (placebo) were used for nasal decolonization. Baseline cultures were taken immediately preoperatively, followed by treatment of both nares twice for 2 minutes with 4 applicators. Reculturing of the right nostril occurred at 4 hours and the left at 24 hours.

RESULTS

Ninety-five of the 429 patients (22.1%) had a positive culture result for S. aureus; 13 (3.03%) were methicillin-resistant S. aureus. Of these 95, 29 were treated with off-the-shelf PI, 34 with SNA, and 32 with saline swabs. At 4 hours post-treatment, S. aureus culture was positive in 52% off-the-shelf PI patients, 21% SNA patients, and 59% saline patients. After 24 hours posttreatment, S. aureus culture was positive in 72% off-the-shelf PI patients, 59% SNA patients, and 69% saline group. SNA was significantly more effective at decolonizing S. aureus over the 4-hour time interval (P = .003); no significant difference was observed over the 24-hour time interval between the 3 groups.

CONCLUSION

A single application of PI-based SNA before surgery may be effective in eliminating nasal S. aureus in over two-thirds of patients. Off-the-shelf PI swabs were not as effective at 4 hours as the specifically manufactured product for S. aureus decolonization.

Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis

BACKGROUND

Pectus excavatum repair (PEX) is among the most painful thoracic procedures performed. Continuous peripheral nerve blockade (CPNB) is known to be efficacious in optimizing pain control while limiting narcotic use in adult thoracic procedures. It was introduced in May 2015 as a bridge to oral pain control in children undergoing PEX. Consequently, the surgical site infection (SSI) rate increased from 2.7% to 27.7%.

METHODS

SSI surveillance followed national guidelines. The abrupt increase prompted root cause analysis and cessation of CPNB use. A dynamic systems model of SSI in PEX was developed. Statistical analysis compared SSI outcomes with and without CPNB.

RESULTS

From May 2015 to June 2015, 21 PEX were performed; 11 with CPNB. 6 SSIs were observed. Use of CPNB significantly (p=0.008) increased SSI incidence. Haller index, number of bars, usage of Fiberwire®, methicillin resistant S. aureus colonization and length of stay did not differ. Root cause analysis revealed the proximity of CPNB catheters to the wound, the use of CPNB with implanted hardware and a delayed utilization of CPNB catheters to be of concern.

CONCLUSION

Introduction of CPNB coincided with a significant increase in SSI. Further study is needed to assess the safety of CPNB in pediatric PEX.

LEVEL OF EVIDENCE

Level III treatment study.

Should preoperative showering or cleansing with chlorhexidine gluconate (CHG) be part of the surgical care bundle to prevent surgical site infection?

Showering preoperatively with chlorhexidine gluconate is an issue that continues to promote debate; however, many studies demonstrate evidence of surgical site infection risk reduction. Methodological issues have been present in many of the studies used to compile guidelines and there has been a lack of standardisation of processes for application of the active agents in papers pre-2009. This review and commentary paper highlights the potential for enhancing compliance with this low-risk and low-cost intervention and provides some guidance for enhancing implementation of preoperative showering with both chlorhexidine in solution and impregnated wipes.

Does a quality improvement campaign accelerate take-up of new evidence? A ten-state cluster-randomized controlled trial of the IHI's Project JOINTS

Background

A decade ago, the Institute for Healthcare Improvement pioneered a quality improvement (QI) campaign, leveraging organizational and personal social networks to disseminate new practices. There have been few rigorous studies of the QI campaign approach.

Methods

Project JOINTS (Joining Organizations IN Tackling SSIs) engaged a network of state-based organizations and professionals in a 6-month QI campaign promoting adherence to three new evidence-based practices known to reduce the risk of infection after joint replacement. We conducted a cluster-randomized trial including ten states (five campaign states and five non-campaign states) with 188 hospitals providing joint replacement to Medicare. We measured adherence to the evidence-based practices before and after the campaign using a survey of surgical staff and a difference-in-difference design with multivariable adjustment to compare adherence to each of the relevant practices and an all-or-none composite measure of the three new practices.

Results

In the campaign states, there were statistically significant increases in adherence to the three new evidence-based practices promoted by the campaign. Compared to the non-campaign states, the relative increase in adherence to the three new practices in the campaign states ranged between 1.9 and 15.9 percentage points, but only one of these changes (pre-operative nasal screening for Staphylococcus aureus carriage and decolonization prior to surgery) was statistically significant (p < 0.05). On the all-or-none composite measure, adherence to all three evidence-based practices increased from 19.6 to 37.9% in the campaign states, but declined slightly in the comparison states, yielding a relative increase of 23 percentage points (p = 0.004). In the non-campaign states, changes in adherence were not statistically significant.

Conclusions

Within 6 months, in a cluster-randomized trial, a multi-state campaign targeting hospitals and professionals involved in surgical care and infection control was associated with an increase in adherence to evidence-based practices that can reduce surgical site infection.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0579-7) contains supplementary material, which is available to authorized users.

Standardizing preoperative preparation to reduce surgical site infections among pediatric neurosurgical patients

OBJECTIVE Surgical site infections (SSIs) are costly to patients and the health care system. Pediatric neurosurgery SSI risk factors are not well defined. Intraoperative protocols have reduced, but have not eliminated, SSIs. The effect of preoperative intervention is unknown. Using quality improvement methods, a preoperative SSI prevention protocol for pediatric neurosurgical patients was implemented to assess its effect on SSI rate. METHODS Patients who underwent a scheduled neurosurgical procedure between January 2014 and December 2015 were included. Published evidence and provider consensus were used to guide preoperative protocol development. The Model for Improvement was used to test interventions. Intraoperative and postoperative management was not standardized or modified systematically. Staff, family, and overall adherence was measured as all-or-nothing. In addition, SSI rates among eligible procedures were measured before and after protocol implementation. RESULTS Within 4 months, overall protocol adherence increased from 51.3% to a sustained 85.7%. SSI rates decreased from 2.9 per 100 procedures preintervention to 0.62 infections postintervention (p = 0.003). An approximate 79% reduction in SSI risk was identified (risk ratio 0.21, 95% CI 0.08-0.56; p = 0.001). CONCLUSIONS Clinical staff and families successfully collaborated on a standardized preoperative protocol for pediatric neurosurgical patients. Standardization of the preoperative phase of care alone reduced SSI rates. Attention to the preoperative in addition to the intraoperative and postoperative phases of care may lead to further reduction in SSI rates.

Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty

BACKGROUND

Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive.

METHODS

We reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a "screen and treat" program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs.

RESULTS

With a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA.

CONCLUSION

Our universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery

Surgical site infections (SSIs) are serious adverse events hindering surgical patients' recovery. In Australia and New Zealand, SSIs are a huge burden to patients and healthcare systems. A bundled approach, including pre-theatre nasal and/or skin decolonization has been used to reduce the risk of staphylococcal infection. The aim of this review is to assess the effectiveness of the bundle in preventing SSIs for cardiac and orthopaedic surgeries. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Published literature was searched in PubMed, Embase and Cochrane Library of Systematic reviews. Identified articles were selected and extracted based on a priori defined Population-Intervention-Comparator-Outcome and eligibility criteria. Data of randomized controlled trials (RCTs) and comparative observational studies were synthesized by meta-analyses. Quality appraisal tools were used to assess the evidence quality. The review included six RCTs and 19 observational studies. The bundled treatment regimens varied substantially across all studies. RCTs showed a trend of Staphylococcus aureus SSIs reduction due to the bundle (relative risk = 0.59, 95% confidence interval (CI) = 0.33, 1.06) with moderate heterogeneity. Observational studies showed statistically significant reduction in all-cause and S. aureus SSIs, with 51% (95% CI = 0.41, 0.59) and 47% (95% CI = 0.35, 0.65), respectively. No publication biases were detected. SSIs in major cardiac and orthopaedic surgeries can be effectively reduced by approximately 50% with a pre-theatre patient care bundle approach.

Intra-Articular Vancomycin Powder Eliminates Methicillin-Resistant S. aureus in a Rat Model of a Contaminated Intra-Articular Implant

BACKGROUND

Periprosthetic joint infection following hip and knee arthroplasty leads to poor outcomes and exorbitant costs. Topical vancomycin powder has been shown to decrease infection in many procedures such as spine surgery. The role of vancomycin powder in the setting of total joint arthroplasty remains undefined. Our aim was to evaluate the efficacy of intra-articular vancomycin powder in preventing infection in a rat model of a contaminated intra-articular implant.

METHODS

Thirty-two female Sprague-Dawley rats underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. The knee joint was also inoculated with 1.5 × 10 colony forming units (CFU)/mL of methicillin-resistant Staphylococcus aureus (MRSA). Four treatment groups were studied: (1) no antibiotics (control), (2) preoperative systemic vancomycin, (3) intra-articular vancomycin powder, and (4) both systemic vancomycin and intra-articular vancomycin powder. The animals were killed on postoperative day 6, and distal femoral bone, joint capsule, and the implanted wire were harvested for bacteriologic analysis. Statistical analyses were performed using Wilcoxon rank sum and Fisher exact tests.

RESULTS

There were no postoperative deaths, wound complications, signs of vancomycin-related toxicity, or signs of systemic illness in any of the treatment groups. There were significantly fewer positive cultures in the group that received vancomycin powder in combination with systemic vancomycin compared with the group that received systemic vancomycin alone (bone: 0% versus 75% of 8, p = 0.007; Kirschner wire: 0% versus 63% of 8, p = 0.026; whole animal: 0% versus 88% of 8, p = 0.01). Only animals that received both vancomycin powder and systemic vancomycin showed evidence of complete elimination of bacterial contamination.

CONCLUSIONS

In a rat model of a contaminated intra-articular implant, use of intra-articular vancomycin powder in combination with systemic vancomycin completely eliminated MRSA bacterial contamination. Animals treated with systemic vancomycin alone had persistent MRSA contamination.

CLINICAL RELEVANCE

This animal study presents data suggesting that the use of intra-articular vancomycin powder for reducing the risk of periprosthetic joint infections should be investigated further in clinical studies.

Implementing Evidence-Based Practice to Reduce Infections Following Arthroplasty

Surgical site infections can have a devastating effect on a patient's morbidity impacting their quality of life and productivity in society. Financial burdens are placed on healthcare organizations because of surgical site infections as well. Evidence has shown that it is a worthwhile endeavor to implement a practice to screen and treat patients who are nasal carriers of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus. Implementing evidence-based practices to combat surgical site infections can help ensure quality healthcare, while producing best possible patient outcomes; however, getting evidence to the bedside can be a challenge. The Johns Hopkins nursing evidence-based practice model is designed to help nurses translate evidence into practice. This article describes the steps one community hospital took to implement an evidence-based practice using the Johns Hopkins model to decrease the likelihood of methicillin-resistant Staphylococcus aureus surgical site infections in patients undergoing total knee arthroplasty and total hip arthroplasty.

Risk Factors for Surgical Site Infections Following Neurosurgical Spinal Fusion Operations: A Case Control Study

OBJECTIVE To determine risk factors for the development of surgical site infections (SSIs) in neurosurgery patients undergoing spinal fusion. DESIGN Retrospective case-control study. SETTING Large, academic, quaternary care center. PATIENTS The study population included all neurosurgery patients who underwent spinal fusion between August 1, 2009, and August 31, 2013. Cases were defined as patients in the study cohort who developed an SSI. Controls were patients in the study cohort who did not develop an SSI. METHODS To achieve 80% power with an ability to detect an odds ratio (OR) of 2, we performed an unmatched case-control study with equal numbers of cases and controls. RESULTS During the study period, 5,473 spinal fusion procedures were performed by neurosurgeons in our hospital. With 161 SSIs recorded during the study period, the incidence of SSIs associated with these procedures was 2.94%. While anterior surgical approach was found to be a protective factor (OR, 0.20; 95% confidence interval [CI], 0.08-0.52), duration of procedure (OR, 1.58; 95% CI, 1.29-1.93), American Society of Anesthesiologists score of 3 or 4 (OR, 1.79; 95% CI, 1.00-3.18), and hospitalization within the prior 30 days (OR, 5.8; 95% CI, 1.37-24.57) were found in multivariate analysis to be independent predictors of SSI following spinal fusion. Prior methicillin-resistant Staphylococcus aureus (MRSA) nares colonization was highly associated with odds 20 times higher of SSI following spinal fusion (OR, 20.30; 95% CI, 4.64-8.78). CONCLUSIONS In additional to nonmodifiable risk factors, prior colonization with MRSA is a modifiable risk factor very strongly associated with development of SSI following spinal fusion. Infect Control Hosp Epidemiol 2017;38:348-352.

Reducing Length of Stay in Total Joint Arthroplasty Care

As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay.

Infection preventionists and laboratorians: Case studies on successful collaboration

Efforts to reduce the incidence of hospital-acquired infection (HAI) remain a significant focus for health care facilities, particularly in this era of drug-resistant organisms. With as many as 1 in every 25 hospitalized patients acquiring an infection, the need to minimize the risk of HAIs is widely recognized as critical. Advances in the fields of biomedical technology, microbiology, pharmacology, and infection control and prevention, among others, have played a tremendous role in these efforts. However, evidence suggests that a key element in this battle against HAIs is missing: collaboration and communication between these groups in health care facilities-particularly in microbiology and infection prevention. The need for collaboration between infection preventionists (IPs) and laboratorians has been addressed in the literature; however, a survey conducted by the APIC and the American Society for Microbiology demonstrated that both IPs and laboratorians feel they lack the tools to engage in this collaboration. This article addresses strategies for a working partnership between IPs and laboratorians and reports 3 case studies on successful collaborations at major medical centers.

Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus Screening and Decolonization to Reduce Surgical Site Infection in Elective Total Joint Arthroplasty

BACKGROUND

Deep infection after elective total joint arthroplasty remains a devastating complication. Preoperative nasal swab screening for Staphylococcus aureus colonization and subsequent treatment of colonized patients is one proposed method to identify at-risk patients and decrease surgical site infections (SSIs). The purpose of this study was to determine whether a preoperative staphylococcus screening and treatment program would decrease the incidence of SSI in elective joint arthroplasty patients.

METHODS

Since January 2009, a total of 9690 patients having an elective joint arthroplasty were screened before surgery for Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) with nares swabs. All patients with positive nare colonization for MSSA and MRSA were treated with mupirocin and chlorhexidine gluconate showers for 5 days before surgery. MRSA patients received vancomycin preoperatively and were placed in contact isolation. All elective arthroplasty patients used chlorhexidine gluconate antiseptic cloths the evening prior and the day of surgery. Perioperative infection rates were compared from 1 year before implementation to 5 years after implementation of this screening protocol.

RESULTS

SSI rates have decreased from 1.11% (prescreening) to 0.34% (nasal screening; P < .05) after initiation of the process. Staphylococcus was identified in 66.7% of the SSI infections before nasal screening and in 33.3% of the SSI after routine screening (P > .05).

CONCLUSION

The addition of MRSA and/or MSSA nares screening along with a perioperative decolonization protocol has resulted in a decreased SSI rate by 69%.

Predictors of Staphylococcus aureus Colonization and Results after Decolonization

Protocols for the screening and decolonization of Staphylococcus aureus prior to total joint arthroplasty (TJA) have become widely adopted. The goals of this study were to determine: (1) whether implementation of a screening protocol followed by decolonization with mupirocin/vancomycin and chlorhexidine reduces the risk of revision compared with no screening protocol (i.e., chlorhexidine alone) and (2) whether clinical criteria could reliably predict colonization with MSSA and/or MRSA. Electronic medical records of primary patients undergoing TJA that were screened (n = 3,927) and were not screened (n = 1,751) for Staphylococcus aureus at least 4 days prior to surgery, respectively, were retrospectively reviewed. All patients received chlorhexidine body wipes preoperatively. Patients carrying MSSA and MRSA were treated preoperatively with mupirocin and vancomycin, respectively, along with the standard preoperative antibiotics and chlorhexidine body wipes. Screened patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened (p = 0.04). Multivariate regression models were poorly accurate in predicting colonization with MSSA (AUC = 0.58) and MRSA (AUC = 0.62). These results support the routine screening and decolonization of S. aureus prior to TJA.

Staphylococcus aureus: the current state of disease, pathophysiology and strategies for prevention

Staphylococcus aureus is both a commensal organism and also an important opportunistic human pathogen, causing a variety of community and hospital-associated pathologies, such as bacteremia-sepsis, endocarditis, pneumonia, osteomyelitis, arthritis and skin diseases. The resurgence of S. aureus during the last decade in many settings has been facilitated not only by bacterial antibiotic resistance mechanisms but also by the emergence of new S. aureus clonal types with increased expression of virulence factors and the capacity to neutralize the host immune response. Prevention of the spread of S. aureus infection relies on the use of contact precautions and adequate procedures for infection control that so far have not been fully effective. Prevention using a prophylactic vaccine would complement these processes, having the potential to bring additional, significant progress toward decreasing invasive disease due to S. aureus.

Evaluation of antimicrobial prophylaxis against postoperative infection after spine surgery: Limit of the first generation cephem

In our department, first-generation cephem (CEZ) are generally administered for 2 days as antimicrobial prophylaxis (AMP) for spinal surgery. However, the incidence of surgical site infection (SSI) has recently increased, particularly cases involving coagulase-negative Staphylococci (CNS) as an etiologic agent. The objective was to elucidate the problems with the current AMP and the risk factors of SSI through a retrospective investigation of affected cases. The subjects were patients who underwent spine surgery at our department between August 2007 and June 2013. The subjects were divided into those who developed SSI (S group) and who did not develop SSI (non-SSI (N) group), patients who developed CNS infection in the S group was subdivided as C group, and the risk factors were investigated. The significance of each factor was analyzed using cross tabulation, and multivariate logistic regression analyses were performed with 22 of the investigation factors as explanatory variables. The incidence of SSI was 2.55%, and the etiologic agent was CNS in 17 patients. Upon comparison between the S and N groups, the presence of 3 or more underlying diseases and blood loss were extracted as significant risk factors. Upon comparison between the C and N groups, emergency surgery and intra- and postoperative steroid administration were extracted as significant risk factors, in addition to the presence of 3 or more underlying diseases and blood loss. The effect of the current AMP using first generation cephem is limited, and reconsideration of the protocol may be necessary.

Postoperative complications of spine surgery

A variety of surgical approaches are available for the treatment of spine diseases. Complications can arise intraoperatively, in the immediate postoperative period, or in a delayed fashion. These complications may lead to severe or even permanent morbidity if left unrecognized and untreated [1-4]. Here we review a range of complications in the early postoperative period from more benign complications such as postoperative nausea and vomiting (PONV) to more feared complications leading to permanent loss of neurological function or death [5]. Perioperative pain management is covered in a separate review (Chapter 8).

Preoperative Staphylococcus aureus Screening/Decolonization Protocol Before Total Joint Arthroplasty-Results of a Small Prospective Randomized Trial

To study the prevalence of Staphylococcus aureus carriage and the impact of preoperatively treating carriers in prosthetic joint infection (PJI), a prospective randomized trial was organized. From January 2010 to December 2012, 1028 of 1305 total joint arthroplasties performed were screened, and selected carriers underwent preoperative decolonization. We observed a 22.2% (228/1028) S aureus colonization rate and only 0.8% methicillin-resistant S aureus. Prosthetic joint infection rate was higher, albeit not significantly, in S aureus carriers than among noncarriers-3.9% (9/228) vs 2.0% (16/800). Treated and untreated carriers showed no significant differences-3.4% (3/89) vs 4.3% (6/139). Most of the 14 S aureus PJI occurred in noncarriers suggesting a lack of causal relation between nasal and PJI S aureus. No clear benefit in screening/decolonizing carriers before total joint arthroplasty could be demonstrated.

Prevalence of MRSA colonization in an adult urban Indian population undergoing orthopaedic surgery

INTRODUCTION

Orthopaedic surgery is technically demanding, implant dependant and expensive. Infection translates into a prolonged morbidity and long-term use of antibiotics. The most common organism involved in osteo-articular infections is Staphylococcus aureus, and colonizes the anterior nares of 25-30% of the population. Carriers are at higher risk for staphylococcal infections after invasive medical or surgical procedures. Prevalence of methicillin resistant Staphylococcus aureus (MRSA) has not been assessed in patients admitted for orthopaedic surgery in the Indian setting.

AIM

To assess the preoperative prevalence of MRSA colonization in adult patients undergoing orthopaedic surgery in urban India.

MATERIALS AND METHODS

This is a retrospective analysis of patients from 2009 to 2013. A total of 1550 patients admitted for orthopaedic surgery were preoperatively screened with nasal and axillary swabs for MRSA. Swab-positive patients were treated with intranasal mupirocin ointment for 3 days followed by a repeat swab. A record was made of hospitalization in the year prior to surgery and the occurrence of surgical site infection (SSI).

RESULTS

A total of 690 males and 860 females had been screened for MRSA using an inexpensive kit costing 500 Indian rupees. For MRSA, 7/1550 (0.45%) nasal swabs were positive. No patient since 2009 has had a SSI with MRSA.

CONCLUSION

MRSA screening prior to orthopaedic surgery is a valuable and cost effective preoperative investigation even though the incidence is low. Mupirocin is effective in clearing MRSA from the nares and maybe used for 3 days to obtain elimination of the bacteria.