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Fernández-Rodríguez D, Cho J, Chisari E, Citardi MJ, Parvizi J. Nasal microbiome and the effect of nasal decolonization with a novel povidone-iodine antiseptic solution: a prospective and randomized clinical trial. Sci Rep 2024; 14:16739. [PMID: 39033201 PMCID: PMC11271270 DOI: 10.1038/s41598-023-46792-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/05/2023] [Indexed: 07/23/2024] Open
Abstract
The aim of this study was to assess the profile of nasal microbiome and evaluate the effect of a specific nasal decolonization solution on the microbiome. We conducted a randomized, placebo-controlled, and parallel-group clinical study of 50 volunteers aged 18 years and older. The subjects were randomly assigned to receive a nasal antiseptic solution, containing povidone-iodine as the main ingredient, (n = 25) or a control solution (n = 25). Nasal swabs were obtained before application (baseline) and at 3 timepoints after application (5 min, 2 h, 24 h). Nasal swabs were subjected to next generation sequencing analysis and cultured in agar plates. At baseline, there were substantial associations between anaerobic species, Corynebacterium spp., Staphylococcus spp., and Dolosigranulum spp. Then, a high bioburden reduction was observed after the application of povidone-iodine (log10 3.68 ± 0.69 at 5 min; log10 3.57 ± 0.94 at 2 h; log10 1.17 ± 1.40 at 24 h), compared to the control. The top species affected by the treatment were Cutibacterium acnes, Staphylococcus, and Corynebacterium species. None of the subjects experienced any adverse effects, nor increases in mucociliary clearance time. Antiseptic solutions applied to the anterior nares can transiently and markedly reduce the bioburden of the nose. The registration number for this clinical trial is NCT05617729.
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Affiliation(s)
- Diana Fernández-Rodríguez
- Rothman Orthopaedic Institute, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA
- Plan de Estudios Combinados en Medicina (PECEM), Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Jeongeun Cho
- Rothman Orthopaedic Institute, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA
| | - Emanuele Chisari
- Rothman Orthopaedic Institute, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA
| | - Martin J Citardi
- Department of Otorhinolaryngology-Head and Neck Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute, 125 S 9th St. Ste 1000, Philadelphia, PA, 19107, USA.
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Bianco Prevot L, Tansini L, Riccardo A, Bolcato V, Tronconi LP, Basile G. Cutting Periprosthetic Infection Rate: Staphylococcus aureus Decolonization as a Mandatory Procedure in Preoperative Knee and Hip Replacement Care-Insights from a Systematic Review and Meta-Analysis of More Than 50,000 Patients. J Clin Med 2024; 13:4197. [PMID: 39064238 PMCID: PMC11277874 DOI: 10.3390/jcm13144197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/05/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Background: No consensus in the literature has been found about the necessity of implementing a decolonization screening protocol for Staphylococcus aureus in patients who undergo prosthesis implantation of the knee (TKA) or of the hip (THA), with the aim of reducing periprosthetic infections (PJIs). Methods: A systematic literature search was conducted using PubMed, Web of Science, and Embase in April 2024. Studies conducted on patients who underwent a TKA or THA and who followed a screening and decolonization protocol from S. aureus were included. The benefits of implementing this protocol were evaluated through the number of infections overall caused by S. aureus and other pathogens. The risk of bias and quality of evidence were assessed using Cochrane guidelines. Results: A total of 922 articles were evaluated, and of these, 12 were included in the study for a total of 56,930 patients. The results of the meta-analysis showed a reduced risk of overall PJI (p = 0.002), PJI caused by S. aureus (p < 0.0001), and PJI caused by MRSA (p < 0.0001) and highlighted no differences between the two groups in the onset of a PJI caused by other bacteria (p = 0.50). Conclusions: This study showed that the screening and decolonization of S. aureus in patients undergoing THA or THA procedures reduced the risk of a PJI. The screening and decolonization protocol for this kind of patient represents an important procedure for the safety of the patient and in social-economic and medico-legal terms.
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Affiliation(s)
- Luca Bianco Prevot
- Residency Program in Orthopedics and Traumatology, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
- Department of Trauma Surgery, IRCCS Ospedale Galeazzi, S. Ambrogio, Via Cristina Belgioioso 173, 20157 Milan, Italy; (A.R.); (G.B.)
| | - Luca Tansini
- Residency Program in Orthopedics and Traumatology, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Accetta Riccardo
- Department of Trauma Surgery, IRCCS Ospedale Galeazzi, S. Ambrogio, Via Cristina Belgioioso 173, 20157 Milan, Italy; (A.R.); (G.B.)
| | | | - Livio Pietro Tronconi
- Department of Human Sciences, European University of Rome, Via degli Aldobrandeschi 190, 00163 Rome, Italy;
- Maria Cecilia Hospital, Via Corriera, 1, 48033 Cotignola, Italy
| | - Giuseppe Basile
- Department of Trauma Surgery, IRCCS Ospedale Galeazzi, S. Ambrogio, Via Cristina Belgioioso 173, 20157 Milan, Italy; (A.R.); (G.B.)
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Von Rehlingen-Prinz F, Röhrs M, Sandiford N, Garcia EG, Schulmeyer J, Salber J, Lausmann C, Gehrke T, Citak M. Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05315-4. [PMID: 38653834 DOI: 10.1007/s00402-024-05315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures. METHODS Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients. RESULTS Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening. CONCLUSION Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.
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Affiliation(s)
- Fidelius Von Rehlingen-Prinz
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Michael Röhrs
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Nemandra Sandiford
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Eva Gomez Garcia
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Juan Schulmeyer
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Bochum, Bochum, Germany
| | - Christian Lausmann
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany.
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Chang Y, Li Y, Fan T, Jiang K, Lv J, Huang J. Pathogenic bacteria characteristics and drug resistance in acute, delayed, and chronic periprosthetic joint infection: A retrospective analysis of 202 patients. Int Wound J 2023; 20:3315-3323. [PMID: 37186450 PMCID: PMC10502290 DOI: 10.1111/iwj.14212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
To assist orthopaedic surgeons in choosing appropriate antibiotics, this study attempted to identify the common microorganisms that cause periprosthetic joint infection (PJI) and their respective drug resistance spectrums. The clinical data of 202 patients with PJI after primary hip and knee arthroplasty between January 2017 and December 2021 were retrospectively analysed. There were 84 males and 118 females, aged (63.03 ± 13.10) years (range: 24-89 years). A total of 102 and 100 patients underwent total hip and total knee arthroplasty, respectively. Based on the time of postoperative infection, the patients were divided into acute (25 cases), delayed (91 cases), and chronic (86 cases) PJI groups. The results of pathogen species, composition ratio, and drug susceptibility tests were collected. Gram-positive bacteria were the primary causative pathogens of PJI (58.91%, 119/202), and their culture-positive rates in patients with acute, delayed, and chronic PJI were 32.00% (8/25), 62.64% (57/91), and 62.79% (54/86), respectively. Staphylococcus epidermidis and Staphylococcus aureus were the major gram-positive bacteria detected, followed by gram-negative bacteria (29/202, 14.36%), and fungi (4/202, 1.98%). Gram-positive bacteria showed higher resistance to penicillin (81.25%), oxacillin (63.33%), erythromycin (61.17%), and clindamycin (48.35%) and 100% sensitivity to linezolid, vancomycin, daptomycin, and tigecycline. In gram-negative bacteria, the drug resistance rates to cefazolin, gentamicin, furantoin, cefuroxime, ticacillin/clavulanic acid, ceftriaxone, ciprofloxacin, and tobramycin were >50%. However, no vancomycin-resistant bacteria were discovered in the current study. The drug resistance rate to carbapenems was low, ranging from 0% to 3.57%. Gram-positive bacteria are the main causative pathogens of PJI, and the resistance rate of pathogens of chronic PJI is higher than those of delayed and acute PJI. Use of cefuroxime and clindamycin in patients with PJIs should proceed with caution because of the high drug resistance rate. Vancomycin can be used as a first-line antibiotic against gram-positive bacteria. Carbapenems can be used as the first choice against gram-negative bacteria because of to their high sensitivity.
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Affiliation(s)
- Yu Chang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Yongsheng Li
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Ting Fan
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Kai Jiang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Jing Lv
- Department of Clinical LaboratoryHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
| | - Jing Huang
- Department of Clinical PharmacyHonghui Hospital, Xi'an Jiaotong UniversityXi'anShaanxiPeople's Republic of China
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Kwan JC, Flannagan RS, Vásquez Peña M, Heinrichs DE, Holdsworth DW, Gillies ER. Induction Heating Triggers Antibiotic Release and Synergistic Bacterial Killing on Polymer-Coated Titanium Surfaces. Adv Healthc Mater 2023; 12:e2202807. [PMID: 37053473 DOI: 10.1002/adhm.202202807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/30/2023] [Indexed: 04/15/2023]
Abstract
Infection is a major complication associated with orthopedic implants. It often involves the development of biofilms on metal substrates, which act as barriers to the host's immune system and systemic antibiotic treatment. The current standard of treatment is revision surgery, often involving the delivery of antibiotics through incorporation into bone cements. However, these materials exhibit sub-optimal antibiotic release kinetics and revision surgeries have drawbacks of high cost and recovery time. Herein, a new approach is presented using induction heating of a metal substrate, combined with an antibiotic-loaded poly(ester amide) coating undergoing a glass transition just above physiological temperature to enable thermally triggered antibiotic release. At normal physiological temperature, the coating provides a rifampicin depot for >100 days, while heating of the coating accelerates drug release, with >20% release over a 1-h induction heating cycle. Induction heating or antibiotic-loaded coating alone each reduce Staphylococcus aureus (S. aureus) viability and biofilm formation on Ti, but the combination causes synergistic killing of S. aureus as measured by crystal violet staining, determination of bacterial viability (>99.9% reduction), and fluorescence microscopy of bacteria on surfaces. Overall, these materials provide a promising platform enabling externally triggered antibiotic release to prevent and/or treat bacterial colonization of implants.
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Affiliation(s)
- Jan C Kwan
- School of Biomedical Engineering, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B9, Canada
- Bone and Joint Institute, The University of Western Ontario, The Sandy Kirkley Centre for Musculoskeletal Research, University Hospital B6-200, London, Ontario, N6G 2V4, Canada
| | - Ronald S Flannagan
- Department of Microbiology and Immunology, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5C1, Canada
| | - Mónica Vásquez Peña
- School of Biomedical Engineering, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B9, Canada
- Bone and Joint Institute, The University of Western Ontario, The Sandy Kirkley Centre for Musculoskeletal Research, University Hospital B6-200, London, Ontario, N6G 2V4, Canada
| | - David E Heinrichs
- Department of Microbiology and Immunology, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5C1, Canada
| | - David W Holdsworth
- School of Biomedical Engineering, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B9, Canada
- Bone and Joint Institute, The University of Western Ontario, The Sandy Kirkley Centre for Musculoskeletal Research, University Hospital B6-200, London, Ontario, N6G 2V4, Canada
- Imaging Research Laboratories, Robarts Research Institute, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 2B8, Canada
- Department of Medical Biophysics, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5C1, Canada
| | - Elizabeth R Gillies
- School of Biomedical Engineering, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B9, Canada
- Bone and Joint Institute, The University of Western Ontario, The Sandy Kirkley Centre for Musculoskeletal Research, University Hospital B6-200, London, Ontario, N6G 2V4, Canada
- Department of Chemistry, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B7, Canada
- Department of Chemical and Biochemical Engineering, The University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 5B9, Canada
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Bostian PA, Vaida J, Brooks WC, Chaharbakhshi E, Dietz MJ, Klein AE, Murphy TR, Frye BM, Lindsey BA. A Novel Protocol for Nasal Decolonization Using Prolonged Application of an Alcohol-Based Nasal Antiseptic Reduces Surgical Site Infections in Total Joint Arthroplasty Patients: A Retrospective Cohort Study. Surg Infect (Larchmt) 2023; 24:651-656. [PMID: 37638795 DOI: 10.1089/sur.2022.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Background: Current nasal decolonization strategies utilize pre-operative agents without consideration for short-term re-colonization or de novo colonization. Many strategies utilize an antibiotic-based agent, raising concerns of limited gram-negative antimicrobial coverage and the emergence of resistant bacterial strains. This study evaluated the clinical utility of a non-antibiotic, alcohol-based nasal decolonization agent in decreasing surgical site infection (SSI) rates after total joint arthroplasty. Patients and Methods: We retrospectively compared an 18-month cohort of elective primary total joint arthroplasty patients treated peri-operatively with an alcohol-based sanitizer to historical controls. The alcohol-based agent was administered pre-operatively the day of surgery and for two weeks after surgery. Patients were followed for 90 days and assessed for signs or symptoms of SSI. Patient and caregiver compliance was recorded. There were 779 patients included in the experimental group and 647 included in the historical control group. Results: Patients receiving alcohol-based nasal decolonization had a lower rate of SSI compared with controls not receiving nasal decolonization (0.64% [5/779] vs. 1.55% [10/647]; p = 0.048; odds ratio, 2.43). Utilization of an alcohol-based nasal sanitizer in the pre-operative and prolonged post-operative setting decreased infection rates by 41.3% in our elective total joint arthroplasty setting. Conclusions: When used pre- and post-operatively, alcohol-based nasal decolonization of bacteria in patients undergoing total joint arthroplasty led to a substantial decrease in SSIs.
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Affiliation(s)
- Phillip A Bostian
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Justin Vaida
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - William C Brooks
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Edwin Chaharbakhshi
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Matthew J Dietz
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Adam E Klein
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - T Ryan Murphy
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Benjamin M Frye
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
| | - Brock A Lindsey
- Department of Orthopaedics, West Virginia University, Morgantown, West Virginia, USA
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Ashkenazi I, Thomas J, Lawrence KW, Rozell JC, Lajam CM, Schwarzkopf R. Positive Preoperative Colonization With Methicillin Resistant Staphylococcus Aureus Is Associated With Inferior Postoperative Outcomes in Patients Undergoing Total Joint Arthroplasty. J Arthroplasty 2023; 38:1016-1023. [PMID: 36863576 DOI: 10.1016/j.arth.2023.02.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The impact of preoperative nasal colonization with methicillin resistant staphylococcus aureus (MRSA) on total joint arthroplasty (TJA) outcomes is not well understood. This study aimed to evaluate complications following TJA based on patients' preoperative staphylococcal colonization status. METHODS We retrospectively analyzed all patients undergoing primary TJA between 2011 and 2022 who completed a preoperative nasal culture swab for staphylococcal colonization. Patients were 1:1:1 propensity matched using baseline characteristics, and stratified into 3 groups based on their colonization status: MRSA positive (MRSA+), methicillin sensitive staphylococcus aureus positive (MSSA+), and MSSA/MRSA negative (MSSA/MRSA-). All MRSA+ and MSSA + underwent decolonization with 5% povidone iodine, with the addition of intravenous vancomycin for MRSA + patients. Surgical outcomes were compared between groups. Of the 33,854 patients evaluated, 711 were included in final matched analysis (237 per group). RESULTS The MRSA + TJA patients had longer hospital lengths of stay (P = .008), were less likely to discharge home (P = .003), and had higher 30-day (P = .030) and 90-day (P = .033) readmission rates compared to MSSA+ and MSSA/MRSA-patients, though 90-day major and minor complications were comparable across groups. MRSA + patients had higher rates of all-cause (P = .020), aseptic (P = .025) and septic revisions (P = .049) compared to the other cohorts. These findings held true for both total knee and total hip arthroplasty patients when analyzed separately. CONCLUSION Despite targeted perioperative decolonization, MRSA + patients undergoing TJA have longer lengths of stay, higher readmission rates, and higher septic and aseptic revision rates. Surgeons should consider patients' preoperative MRSA colonization status when counseling on the risks of TJA.
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Affiliation(s)
- Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York; Division of Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Jeremiah Thomas
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Kyle W Lawrence
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
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"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members". Knee Surg Sports Traumatol Arthrosc 2022; 30:3932-3943. [PMID: 34518895 DOI: 10.1007/s00167-021-06742-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. METHODS A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively. RESULTS Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status: 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes: 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization: 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative: (A) Antibiotic prophylaxis in high-risk patients: 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing: 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection: 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI: 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain: 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage: 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI: 82.4% use antibiotic-added cement. Postoperative: (A) Routine monitoring of PJI serologic markers: 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI: 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI: 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP. CONCLUSIONS This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas: Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication. LEVEL OF EVIDENCE IV.
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Chang Y, Li Y, Jiang K, Lv J, Huang J. Pathogen distrbution and drug resistance in acute, delayed and chronic periprosthetic joint infection: a retrospective analysis of 202 patients.. [DOI: 10.21203/rs.3.rs-2111407/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Introduction To assist orthopedic surgeons to select appropriate antibiotics, this study identified the common microorganisms that caused PJI and their drug-resistant spectrum.
Methods. The clinical data of 202 patients with PJI after primary knee and hip arthroplasty from January 2017 to December 2021 were retrospectively analyzed. According to the time of postoperative infection, the patients were divided into acute PJI group (25 cases), delayed PJI group (91 cases), and chronic PJI group (86 cases). The results of pathogen species, composition ratio, drug susceptibility tests were collected.
Results.The main pathogens of PJI were Gram-positive bacteria (58.91%, 119/202), and the positive rates of culture in patients with acute PJI, delayed PJI and chronic PJI were 32.00% (8/25), 62.64% (57/91) and 62.79% (54/86), followed by gram-negative bacteria (29/202, 14.36%) and fungus (4/202, 1.98%). Staphylococcus epidermidis and Staphylococcus aureus played an important role as well, followed by gram-negative bacteria (29/202, 14.36%) and fungus (4/202, 1.98%). Penicillin (81.25%), oxacillin (63.33%), erythromycin (61.17%) and clindamycin (48.35%) showed high antibiotic resistance rate in gram-positive bacteria. The drug-sensitivity to linezolid, vancomycin, daptomycin and tigecycline was 100%. The drug resistance rate to carbapenems was low, ranging from 0 to 3.57%.
Conclusions. The main pathogens of PJI are Gram-positive bacteria, and the drug resistance rate of chronic PJI is higher than that of delayed and acute PJI.
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Affiliation(s)
- Yu Chang
- Honghui Hospital, Xi'an Jiaotong University
| | | | - Kai Jiang
- Honghui Hospital, Xi'an Jiaotong University
| | - Jing Lv
- Honghui Hospital, Xi'an Jiaotong University
| | - Jing Huang
- Honghui Hospital, Xi'an Jiaotong University
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10
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Meermans G. CORR Insights®: Preoperative Colonization With Staphylococcus Aureus in THA is Associated With Increased Length of Stay. Clin Orthop Relat Res 2022; 480:1515-1517. [PMID: 35258499 PMCID: PMC9278939 DOI: 10.1097/corr.0000000000002172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Geert Meermans
- Orthopaedic Surgeon, Bravis Hospital, Brabant, the Netherlands
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11
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Salem HS, Sherman AE, Chen Z, Scuderi GR, Mont MA. The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review. J Knee Surg 2022; 35:1023-1043. [PMID: 34875715 DOI: 10.1055/s-0041-1740394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.
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Affiliation(s)
- Hytham S Salem
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Alain E Sherman
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
| | - Zhongming Chen
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Giles R Scuderi
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York
| | - Michael A Mont
- Northwell Health Orthopaedics, Lenox Hill Hospital, New York, New York.,Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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12
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Stapleton EJ, Petrone B, Zois T, Papas V, Frane N, Green E, Scuderi GR. Predictors of Staphylococcus Aureus Nasal Colonization in Joint Arthroplasty Patients. J Knee Surg 2022; 35:661-667. [PMID: 32942335 DOI: 10.1055/s-0040-1716503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Early identification and treatment of Staphylococcus aureus (S. aureus) nasal colonization can reduce the risk of prosthetic joint infection. The purpose of this study was to evaluate patient-specific predictors for S. aureus nasal colonization in total joint arthroplasty patients to aid in preoperative screening protocols. A total of 2,147 arthroplasty patients who were preoperatively screened for S. aureus nasal colonization were retrospectively reviewed. Factors analyzed consisted of procedure type, primary diagnosis, gender, ethnicity, body mass index, the presence of chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension, diabetes mellitus, use of immunosuppression medication, smoking history, and chronic kidney disease. Univariate and multivariate analyses were performed with significance p < 0.05 and 95% confidence intervals. Overall, 3.7% (79) of our cohort tested positive for methicillin-resistant Staphylococcus aureus (MRSA), and 23.2% (493) tested positive for methicillin-sensitive Staphylococcus aureus (MSSA). Independent predictors for MRSA colonization were of Hispanic ethnicity (p = 0.001, odds ratio [OR] 13.98, confidence interval [CI] 2.97-65.76), immunosuppression medication use (p = 0.006, OR 2.82, CI 1.35-5.87), and revision total hip arthroplasty (THA) procedure (p < 0.001, OR 7.51, CI 2.58-21.89). Independent predictors for MSSA colonization were body mass index (BMI) >35 (p = 0.002, OR 1.57, CI 1.19-2.1). Variables were found to be protective against MSSA colonization including female gender (p = 0.012, OR 0.76, CI 0.61-0.94), age 60 to 69 (p = 0.025, OR 0.75, CI 0.58-0.96), and age 70 to 79 (p = 0.002, OR 0.63, CI 0.47-0.84). Age, Hispanic ethnicity, gender, revision THA, use of immunosuppression medication, and elevated BMI were independent risk factors for S. aureus nasal colonization.
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Affiliation(s)
- Erik J Stapleton
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Valley Stream, Valley Stream, New York
| | - Brandon Petrone
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Valley Stream, Valley Stream, New York
| | - Theofanis Zois
- Department of Orthopaedic Surgery, Northwell Health Orthopedic Institute, Lenox Hill Hospital, New York, New York
| | - Vivian Papas
- Department of Orthopaedic Surgery, Northwell Health Orthopedic Institute, Lenox Hill Hospital, New York, New York
| | - Nicholas Frane
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Valley Stream, Valley Stream, New York
| | - Evan Green
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Valley Stream, Valley Stream, New York
| | - Giles R Scuderi
- Department of Orthopaedic Surgery, Northwell Health Orthopedic Institute, Lenox Hill Hospital, New York, New York
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13
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Ingall EM, Grisdela PT, Bejarano-Pineda L, DiGiovanni CW. To Screen or Not to Screen. . . Who Nose? Foot Ankle Int 2022; 43:453-456. [PMID: 34794341 DOI: 10.1177/10711007211052294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Eitan M Ingall
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
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14
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Hatcher JB, de Castro-Abeger A, LaRue RW, Hingorani M, Mawn L, Donahue SP, Sternberg P, Shieh C. MRSA Decolonization and the Eye: A Potential New Tool for Ophthalmologists. Semin Ophthalmol 2022; 37:541-553. [DOI: 10.1080/08820538.2022.2039220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jeremy B Hatcher
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Alex de Castro-Abeger
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Richard W LaRue
- Department of Medicine, Division of Infectious Disease, Vanderbilt Medical Center, Nashville, TN, United States
| | - Melanie Hingorani
- Department of Paediatrics, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Louise Mawn
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sean P Donahue
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Paul Sternberg
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christine Shieh
- Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN, United States
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15
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Valverde Villar AM, Gutiérrez Del Álamo Oms J, Neira Borrajo I, de Miguel Fernández S, Flox Benítez P, Llopis Miró R. Screening of MRSA colonization in patients undergoing total joint arthroplasty. J Infect Prev 2021; 22:283-288. [PMID: 34880951 DOI: 10.1177/17571774211013410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
Background Periprosthetic infection is commonly caused by Staphylococcus aureus and, if resistant to methicillin (MRSA), is associated with increase in severity and costs to patient and healthcare systems. MRSA colonizes 1-5% of the population, therefore using a screening and decolonisation protocol the risk of periprosthetic infection could be reduced. The objective of our study is to report the results of a preoperative MRSA screening and management protocol utilised at our hospital. Methods All patients undergoing a total joint arthroplasty at our hospital were preoperatively screened for MRSA colonization with swab samples of five different locations. Exposure to risk factors were investigated in colonised patients and they were treated for 5 days prior surgery with nasal mupirocin, chlorhexidine sponges and oral tablets. Results During the 48 months of the study, MRSA colonisation was identified in 22 (1.01%) of 2188 patients operated. The culture was positive only in the nasal swab in 55 patients. In five patients the nasal culture was negative, but they had another positive swab culture (three in the groin and two perianal). None of the patients reported a history of recent antibiotic treatment or hospitalization. Conclusion At our institution, the prevalence of MRSA colonisation is 1.01% in patients undergoing hip and knee arthroplasty. Interestingly, our screening protocol included samples from five different anatomic locations, and it is important to highlight that we found patients with negative nares culture and positive cultures in other locations. Therefore, the number of carriers may be underdiagnosed if only nasal samples are obtained. Level of evidence IV.
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Affiliation(s)
- A M Valverde Villar
- Department of Orthopaedic Surgery, Hospital Universitario Santa Cristina, Madrid, Spain
| | | | - I Neira Borrajo
- Department of Orthopaedic Surgery, Hospital Universitario Santa Cristina, Madrid, Spain
| | - S de Miguel Fernández
- Department of Clinical Analysis, Hospital Universitario Santa Cristina, Madrid, Spain
| | - P Flox Benítez
- Department of Pharmacy, Hospital Universitario Santa Cristina, Madrid, Spain
| | - R Llopis Miró
- Department of Orthopaedic Surgery, Hospital Universitario Santa Cristina, Madrid, Spain
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16
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Coia JE, Wilson JA, Bak A, Marsden GL, Shimonovich M, Loveday HP, Humphreys H, Wigglesworth N, Demirjian A, Brooks J, Butcher L, Price JR, Ritchie L, Newsholme W, Enoch DA, Bostock J, Cann M, Wilson APR. Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect 2021; 118S:S1-S39. [PMID: 34757174 DOI: 10.1016/j.jhin.2021.09.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022]
Affiliation(s)
- J E Coia
- Department of Clinical Microbiology, Hospital South West Jutland, Esbjerg, Denmark; Department of Regional Health Research IRS, University of Southern Denmark, Denmark; Healthcare Infection Society, London, UK
| | - J A Wilson
- Richard Wells Research Centre, University of West London, London, UK; Infection Prevention Society, Seafield, UK
| | - A Bak
- Healthcare Infection Society, London, UK.
| | | | - M Shimonovich
- Healthcare Infection Society, London, UK; MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - H P Loveday
- Richard Wells Research Centre, University of West London, London, UK; Infection Prevention Society, Seafield, UK
| | - H Humphreys
- Healthcare Infection Society, London, UK; Department of Clinical Microbiology, The Royal College of Surgeons, Ireland; Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - N Wigglesworth
- Infection Prevention Society, Seafield, UK; East Kent Hospitals University, NHS Foundation Trust, Canterbury, UK
| | - A Demirjian
- Healthcare-associated Infection and Antimicrobial Resistance, Public Health England, London, UK; Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - J Brooks
- Infection Prevention Society, Seafield, UK; University Hospital Southampton NHS Foundation Trust, UK
| | - L Butcher
- Infection Prevention Society, Seafield, UK; Oxford University Hospitals NHS Foundation Trust, UK
| | - J R Price
- Healthcare Infection Society, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - L Ritchie
- Healthcare Infection Society, London, UK; NHS England and NHS Improvement, London, UK
| | - W Newsholme
- Healthcare Infection Society, London, UK; Guy's and St Thomas' NHS Foundation Trust, UK
| | - D A Enoch
- Healthcare Infection Society, London, UK; Clinical Microbiology & Public Health Laboratory, Public Health England, Addenbrooke's Hospital, Cambridge, UK
| | | | - M Cann
- Lay Member, UK; MRSA Action UK, Preston, UK
| | - A P R Wilson
- Healthcare Infection Society, London, UK; University College London Hospitals NHS Foundation Trust, UK.
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17
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Ribau AI, Collins JE, Chen AF, Sousa RJ. Is Preoperative Staphylococcus aureus Screening and Decolonization Effective at Reducing Surgical Site Infection in Patients Undergoing Orthopedic Surgery? A Systematic Review and Meta-Analysis With a Special Focus on Elective Total Joint Arthroplasty. J Arthroplasty 2021; 36:752-766.e6. [PMID: 32950342 DOI: 10.1016/j.arth.2020.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Staphylococcus aureus is a major pathogen implicated in orthopedic infections worldwide. Preoperative decolonization has been promoted but different strategies present mixed results. Thus, the goals of this study are to determine (1) whether S aureus screening and/or decolonization is effective at reducing surgical site infection in orthopedic surgery, (2) with a special focus on elective total joint arthroplasty (TJA), and (3) which preoperative S aureus screening/treatment strategy is most cost-effective for TJA. METHODS PubMed, Ovid MEDLINE, and Cochrane databases were searched on January 1, 2020, using a systematic strategy. We included papers with data comparing surgical site infection and periprosthetic joint infection rate in orthopedic surgery and/or elective total hip and knee arthroplasty patients before/after S aureus screening and/or decolonization protocol and papers evaluating the cost-effectiveness of different S aureus screening/treatment strategies. RESULTS A total of 1260 papers were screened, and 32 papers were ultimately included. Results showed an increased risk of developing any infection (relative risk [RR] = 1.71 ± 0.16) and S aureus infection (RR = 2.79 ± 0.45) after orthopedic surgery without previous nares and whole-body decolonization. Focusing exclusively on elective TJA, there was an increased risk of developing any infection (RR = 1.70 ± 0.17) and S aureus infection (RR = 2.18 ± 0.41) if no decolonization is performed. All strategies appeared to be cost-effective, although universal decolonization without screening seemed to be the most advantageous. CONCLUSION Preoperative S aureus screening/decolonization protocol lowered the risk of infection after elective orthopedic and TJA surgeries. However, further studies are needed to determine optimal clinical and cost-effective methodologies.
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Affiliation(s)
- Ana I Ribau
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal
| | - Jamie E Collins
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ricardo J Sousa
- Department of Orthopedics, Centro Hospitalar do Porto, Porto, Portugal; Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar do Porto and Grupo TrofaSaude - Hospital em Alfena, Portugal
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18
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Lin L, Ke ZY, Wang Y, Chen XL, Zhong D, Cheng S. Efficacy of preoperative screening and decolonization for staphylococcus aureus in total joint arthroplasty: A meta-analysis. Asian J Surg 2021; 44:807-818. [PMID: 33468375 DOI: 10.1016/j.asjsur.2020.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/18/2020] [Accepted: 12/23/2020] [Indexed: 01/11/2023] Open
Abstract
The purpose of this study is to conduct a meta-analysis to evaluate the efficacy of screening and decolonization protocol for Staphylococcus aureus (SA) in total joint arthroplasty (TJA). We systematically searched the electronic databases of PubMed, Embase and Cochrane databases for relevant literatures from January 2000 to September 2020. The outcomes were colonization rate, total-surgical site infection (SSI) rate, SA-SSI rate and methicillin-resistant Staphylococcus aureus (MRSA)-SSI rate. All calculations and statistical tests were performed using Stata 14.0 software. A total of 12 studies were eligible in this study. Compared with control group, the screening and decolonization group had lower risks in total-SSI (risk ratio (RR) = 0.52; 95% confidence interval (CI): 0.40-0.67), SA-SSI (RR = 0.48; 95% CI: 0.32-0.72) and MRSA-SSI (RR = 0.45; 95% CI: 0.21-0.96). The nasal SA colonization was found to be associated with higher accidences of SSI involving total-SSI (RR = 1.49; 95% CI: 1.02-2.18), SA-SSI (RR = 2.51; 95% CI: 0.97-6.50) and MRSA-SSI (RR = 7.84; 95% CI: 1.67-36.79). The colonization rate of SA was significantly reduced after decolonization. No difference was observed between universal decolonization and screening-based decolonization. In conclusion, colonization of SA is associated with increased risk of SSI in TJA. Screening and decolonization protocol are proven to be effective to reduce colonization of SA and present protective effects against SSI in TJA. Moreover, universal decolonization protocol is non-inferior to screening-based decolonization.
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Affiliation(s)
- Lu Lin
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen-Yong Ke
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Lin Chen
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dian Zhong
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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19
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Squire MM, Sessel GK, Lin G, Squire EN, Igusa T. Optimal Design of Paired Built Environment Interventions for Control of MDROs in Acute Care and Community Hospitals. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2020; 14:109-129. [PMID: 33375862 DOI: 10.1177/1937586720976585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Our goal was to optimize infection control of paired environmental control interventions within hospitals to reduce methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacteriaceae (CRE), and vancomycin-resistant Enterococci (VRE). BACKGROUND The most widely used infection control interventions are deployment of handwashing (HW) stations, control of relative humidity (RH), and negative pressure (NP) treatment rooms. Direct costs of multidrug-resistant organism (MDRO) infections are typically not included in the design of such interventions. METHODS We examined the effectiveness of pairing HW with RH and HW with NP. We used the following three data sets: A meta-analysis of progression rates from uncolonized to colonized to infected, 6 years of MDRO treatment costs from 400 hospitals, and 8 years of MDRO incidence rates at nine army hospitals. We used these data as inputs into an Infection De-Escalation Model with varying budgets to obtain optimal intervention designs. We then computed the infection and prevention rates and cost savings resulting from these designs. RESULTS The average direct cost of an MDRO infection was $3,289, $1,535, and $1,067 for MRSA, CRE, and VRE. The mean annual incidence rates per facility were 0.39%, 0.034%, and 0.011% for MRSA, CRE, and VRE. After applying the cost-minimizing intervention pair to each scenario, the percentage reductions in infections (and annual direct cost savings) in large, community, and small acute care hospitals were 69% ($1.5 million), 73% ($631K), 60% ($118K) for MRSA, 52% ($460.5K), 58% ($203K), 50% ($37K) for CRE, and 0%, 0%, and 50% ($12.8K) for VRE. CONCLUSION The application of this Infection De-Escalation Model can guide cost-effective decision making in hospital built environment design to improve control of MDRO infections.
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Affiliation(s)
- Marietta M Squire
- Department of Civil and Systems Engineering, 1466Johns Hopkins University, Baltimore, MD, USA
| | - Gareth K Sessel
- Outreach Engineering NPC (Nonprofit Company), Johannesburg, South Africa
| | - Gary Lin
- Department of Emergency Medicine, 1466Johns Hopkins University, Baltimore, MD, USA
| | | | - Takeru Igusa
- Department of Civil and Systems Engineering, 1466Johns Hopkins University, Baltimore, MD, USA
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20
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Hijas-Gómez AI, Checa-García A, López-Hualda Á, Fahandezh-Saddi H, Martínez-Martín J, Gil-Conesa M, Rodríguez-Villar D, Gil-de-Miguel Á, Rodríguez-Caravaca G. Surgical site infection in hip arthroplasty in a 10-year follow-up prospective study: Risk and factors associated. Am J Infect Control 2020; 48:1437-1444. [PMID: 32464296 DOI: 10.1016/j.ajic.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The increased demand for hip arthroplasty means a growing number of postsurgical complications. This study aims to assess the risk of surgical site infection (SSI) in a teaching hospital; develop regional, national and international external comparisons; and evaluate SSI-related risk factors, particularly according to the timing of surgery (urgent/unplanned or elective). METHODS Prospective cohort study from January 2008 to December 2018. Patients were followed up to 90 days after surgery. Primary endpoint was SSI incidence according to the Centers for Disease Control and Prevention criteria. Multivariate analysis was conducted to find independently associated SSI risk factors. The association between risk factors and SSI incidence was assessed by reference to odds ratio (OR). Analyses were also performed among urgent/unplanned and elective patients to identify whether SSI risk factors differed between groups. RESULTS The study population (n = 1,808) has an overall SSI rate of 3.0% (95% confidence interval [CI]: 2.4-3.9). Timing of surgery caused an effect modification, so surgery duration> 75th percentile (OR: 3.8; 95% CI: 1.5-9.8) and inadequate preparation (OR: 3.3; 95% CI: 1.1-10.0) were independent risk factors in the urgent/unplanned group; National Healthcare Safety Network risk index≥ 2 (OR: 6.3; 95% CI: 0.1-19.2) and transfusion (OR: 3.6; 95% CI: 1.1-11.9) in the elective group. CONCLUSIONS Hospital infection surveillance systems allow identifying risk factors susceptible to change. Characterization of factors that caused an effect modification is key to identify areas of quality improvement, including reducing operating times, preventing perioperative blood transfusion, or improving patient preparation before surgery.
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21
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Scholten R, Hannink G, Willemsen K, Mascini EM, Somford MP, Schreurs BW, van Susante JLC. Preoperative Staphylococcus aureus screening and eradication. Bone Joint J 2020; 102-B:1341-1348. [PMID: 32993339 DOI: 10.1302/0301-620x.102b10.bjj-2020-0038.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS Preoperative nasal Staphylococcus aureus screening and eradication reduces surgical site infections (SSIs) but its impact on reducing early prosthetic joint infection (PJI) remains controversial. This study aims to assess the effect of preoperative nasal S. aureus screening and eradication on the incidence of early PJI in general and S. aureus-induced early PJI. METHODS All primary total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed from January 2006 to April 2018 were retrospectively reviewed for the incidence of early PJI. Demographic parameters, risk factors for PJI (American Society of Anaesthesiologists classification, body mass index, smoking status, and diabetes mellitus) and implant types were collected. A preoperative screening and eradication protocol for nasal colonization of S. aureus was introduced in October 2010. The incidence of early PJI was compared before and after the implementation of the protocol. Missing data were imputed via multiple imputation by chained equations. Inverse probability weighting was used to account for differences between patients in both groups. Weighted univariate logistic regression was used to evaluate the incidence of early PJI for both groups. RESULTS In total, 10,486 THAs and TKAs were performed in the research period. After exclusion, a cohort of 5,499 screened cases and 3,563 non-screened cases were available for analysis. Overall, no significant reduction in early PJI was found in the screened group (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.55 to 1.11; p = 0.173). However, the incidence of S. aureus-induced PJI was significantly reduced (OR 0.58, 95% CI 0.36 to 0.92; p = 0.027) in the screened group. CONCLUSION A preoperative nasal S. aureus screening and eradication protocol did not significantly reduce the overall incidence of early PJI after THA or TKA. However, a decreased incidence of S. aureus-induced early PJI was established. These findings can help to establish better consensus around the value of these screening protocols. Cite this article: Bone Joint J 2020;102-B(10):1341-1348.
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Affiliation(s)
- Ruben Scholten
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karin Willemsen
- Department of Infection Control, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - Ellen M Mascini
- Laboratory of Medical Microbiology and Immunology, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - Matthijs P Somford
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the Netherlands
| | - B Willem Schreurs
- Department of Orthopedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Job L C van Susante
- Department of Orthopedic Surgery, Rijnstate Ziekenhuis, Arnhem, the Netherlands
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Bouyer B, Arvieu R, Gerlinger MP, Watier L, Kassis N, Nerome S, Diop A, Mainardi JL, Durieux P, Guigui P. Individual decontamination measures reduce by two the incidence of surgical site infections in spinal surgery. Orthop Traumatol Surg Res 2020; 106:1175-1181. [PMID: 32371016 DOI: 10.1016/j.otsr.2020.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/25/2019] [Accepted: 01/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND In spinal surgery, incidence of surgical site infections (SSI) is estimated between 1 and 10%. It results in increased morbidity, mortality and cost of management. Individual Staphylococcus aureus (SA) decolonization has already proved efficiency to prevent those events in various surgical domains. The aim of this study was to evaluate a strategy of prevention of SSI and in particular the decolonization of the nasal carriage of SA by a protocol with Mupirocin application. METHODS We conducted a bicentric observational study on 5314 spinal surgery patients over a seven-year period. In both center, we compared periods before and after implementation of two measures: modification of antibioprophylaxis and staphylococcus decolonization. Homogeneity of the different samples of patients was assessed through measure of individual and surgical variables. We measured monthly incidence of SSI and evaluated its evolution in order to assess efficiency of these interventions. RESULTS The incidence of SSI decreased by half, from 7.3% to 3% at the Beaujon Hospital and from 8.3% to 3.9% at the Georges-Pompidou European Hospital (GPEH). We do not observe any significant decrease of SA rate in these SSI. CONCLUSION We believe that Staphylococcus aureus decolonization should be recommended in spinal surgery, and should be combined with an overall improvement of the quality of care.
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Affiliation(s)
- Benjamin Bouyer
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, Paris, France; Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France.
| | - Robin Arvieu
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, Paris, France; Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France
| | - Marie-Paule Gerlinger
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France; Unité de microbiologie clinique, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France
| | - Laurence Watier
- Inserm, UMR 1181 biostatistique, biomathématique, pharmacoépidémiologie et maladies infectieuses (B2PHI), Institut Pasteur, université Versailles Saint-Quentin-en-Yvelines, Saint Quentin en Yvelines, France
| | - Najiby Kassis
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France; Inserm, UMR 1181 biostatistique, biomathématique, pharmacoépidémiologie et maladies infectieuses (B2PHI), Institut Pasteur, université Versailles Saint-Quentin-en-Yvelines, Saint Quentin en Yvelines, France
| | - Simone Nerome
- Unité d'hygiène et de lutte contre les infections nosocomiales, hôpital Beaujon, Paris, France; Service d'informatique médicale, hôpital Beaujon, université Paris Diderot, Paris, France
| | - Aziz Diop
- Université Paris Diderot, Paris, France; Service d'informatique médicale, hôpital Beaujon, université Paris Diderot, Paris, France
| | - Jean-Luc Mainardi
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France; Unité de microbiologie clinique, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France
| | - Pierre Durieux
- Service d'informatique médicale, hôpital Beaujon, université Paris Diderot, Paris, France; Service d'informatique médicale, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France
| | - Pierre Guigui
- Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, Paris, France; Service d'orthopédie-traumatologie, hôpital européen Georges-Pompidou, université Paris-Descartes, Paris, France
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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
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Santoso A, Yoon TR, Park KS, Anwar IB, Utomo P, Soetjahjo B, Sibarani T. The Results of Two-stage Revision for Methicillin-resistant Periprosthetic Joint Infection (PJI) of the Hip. Malays Orthop J 2020; 14:18-23. [PMID: 32296477 PMCID: PMC7156181 DOI: 10.5704/moj.2003.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: Periprosthetic joint infection (PJI) of the hip due to methicillin-resistant bacteria is difficult to treat and remain a challenge for arthroplasty surgeon. Material and Methods: Retrospective review was done to the patients who received two-stage revisions with an antibiotic loaded cement-spacer for PJI of the hip between January 2010 to May 2015. We found 65 patients (65 hips) with positive culture findings. Eight patients were lost to follow-up and excluded from the study. Among the rest of the 57 patients, methicillin-resistant infection (MR Group) was found in 28 cases. We also evaluate the 29 other cases that caused by the other pathogen as control group. We compared all of the relevant medical records and the treatment outcomes between the two groups. Results: The mean of follow-up period was 33.7 months in the methicillin-resistant group and 28.4 months in the control group (p = 0.27). The causal pathogens in the methicillin-resistant group were: Methicillin-resistant Staphylococcus aureus (MRSA) in 10 cases, Methicillin-resistant Staphylococcus epidermidis (MRSE) in 16 cases and Methicillin-resistant coagulase-negative Staphylococcus (MRCNS) in two cases. The reimplantation rate was 92.8% and 89.6% in the methicillin-resistant and control group, respectively (p= 0.66). The rates of recurrent infection after reimplantation were 23.1% (6/26) in the methicillin-resistant group and 7.6% (2/26) in the control group (p= 0.12). The overall infection control rate was 71.4% (20/28) and 89.6% (26/29) in the methicillin-resistant and control group, respectively (p = 0.08). Both groups showed comparable baseline data on mean age, BMI, gender distribution, preoperative ESR/CRP/WBC and comorbidities. Conclusions: Two-stage revision procedure resulted in low infection control rate and high infection recurrency rate for the treatment of methicillin-resistant periprosthetic joint infection (PJI) of the hip. Development of the treatment strategy is needed to improve the outcome of methicillin-resistant periprosthetic joint infection (PJI) of the hip.
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Affiliation(s)
- A Santoso
- Department of Orthopaedic and Traumatology, Universitas Sebelas Maret, Solo, Indonesia
| | - T R Yoon
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Jeonnam, Republic of Korea
| | - K S Park
- Department of Orthopaedic Surgery, Chonnam National University Bitgoeul Hospital, Jeonnam, Republic of Korea
| | - I B Anwar
- Department of Orthopaedic and Traumatology, Universitas Sebelas Maret, Solo, Indonesia
| | - P Utomo
- Department of Orthopaedic and Traumatology, Universitas Sebelas Maret, Solo, Indonesia
| | - B Soetjahjo
- Department of Orthopaedic and Traumatology, Universitas Sebelas Maret, Solo, Indonesia
| | - T Sibarani
- Department of Orthopaedic and Traumatology, Universitas Sebelas Maret, Solo, Indonesia
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Zhu X, Sun X, Zeng Y, Feng W, Li J, Zeng J, Zeng Y. Can nasal Staphylococcus aureus screening and decolonization prior to elective total joint arthroplasty reduce surgical site and prosthesis-related infections? A systematic review and meta-analysis. J Orthop Surg Res 2020; 15:60. [PMID: 32075670 PMCID: PMC7031963 DOI: 10.1186/s13018-020-01601-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Background Nasal Staphylococcus aureus (S. aureus) screening and decolonization has been widely used to reduce surgical site infections (SSIs) prior to total knee and hip arthroplasty (TKA and THA). However, it remains considerably controversial. The aim of this study was to ascertain whether this scheme could reduce SSIs and periprosthetic joint infections (PJIs) following elective primary total joint arthroplasty (TJA). Methods A systematic search was performed in MEDLINE, Embase, and the Cochrane Library until October, 2019. Outcomes of interest included SSI, PJI, superficial infection, and different bacterial species that caused infections. Data from eligible studies were then extracted and synthesized. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated. We also performed additional analyses to evaluate whether there were differences in postoperative SSIs caused by S. aureus or other bacteria. Results Nine studies were included in our meta-analysis. The pooled data elucidated that nasal S. aureus screening and decolonization dramatically mitigated the risk of SSI, PJI, and superficial infection compared to nondecolonization group. The analysis of bacterial species causing infection also showed that the S. aureus infections postoperative were significantly decreased in the decolonization group. However, there was no statistical difference in the SSI caused by other bacteria between the two groups. Conclusion S. aureus screening and decolonization prior to elective primary THA and TKA could significantly decrease the risk of SSI and PJI. However, more robust studies are needed to further evaluate the impact of S. aureus screening and decolonization on infection risk after TJA.
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Affiliation(s)
- Xingyang Zhu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Yichuan People's Hospital, Jiuchang Road 21#, District Yichuan, Luoyang, Henan, China
| | - Xiaobo Sun
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Yuqing Zeng
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Wenjun Feng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jie Li
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Jianchun Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China
| | - Yirong Zeng
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Jichang Road 16#, District Baiyun, Guangzhou, 510405, Guangdong, China.
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Couture A, Lavergne V, Sandman E, Leduc JM, Benoit B, Leduc S, Rouleau DM. Calcium sulphate mixed with antibiotics does not decrease efficacy against Cutibacterium acnes (formerly Propionibacterium acnes), in vitro study. J Orthop 2020; 19:138-142. [PMID: 32025121 DOI: 10.1016/j.jor.2019.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022] Open
Abstract
Background This study explored the in vitro efficacy of antibiotics mixed with calcium sulfate (ACS) against Cutibacterium acnes (C. acnes). Methods C. acnes isolates from orthopaedic infection sites were tested for antimicrobial susceptibility with ACS. Minimal inhibitory concentrations (MIC) were determined with a gradient diffusion method (Etest® strips). Results When tested with Etest®, all 22 isolates were susceptible to penicillin, ceftriaxone, vancomycin, and two were resistant to clindamycin (MICs of 4 and 8 mg/L). Penicillin and rifampin had the largest inhibition zone diameters. Conclusions Antibiotics retained activity against C. acnes when mixed with calcium sulfate.
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Affiliation(s)
- Anne Couture
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada
| | - Valéry Lavergne
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Emilie Sandman
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Jean-Michel Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Benoit Benoit
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Stéphane Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Dominique M Rouleau
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
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Pelfort X, Romero A, Brugués M, García A, Gil S, Marrón A. Reduction of periprosthetic Staphylococcus aureus infection by preoperative screening and decolonization of nasal carriers undergoing total knee arthroplasty. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:426-431. [PMID: 31537434 PMCID: PMC6938997 DOI: 10.1016/j.aott.2019.08.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 04/12/2019] [Accepted: 08/26/2019] [Indexed: 02/03/2023]
Abstract
Objective The aim of this study was to evaluate whether the establishment of a preoperative screening and decolonization protocol for Staphylococcus aureus carriers undergoing total knee arthroplasty (TKA) could decrease the incidence of periprosthetic joint infection (PJI) caused by this microorganism. Methods We conducted a retrospective study comparing a control group comprising 400 patients (134 men, and 266 women; mean age: 72.2 ± 6.8 years) who went through surgery between January 2009 and December 2013, with a second intervention group of 403 patients (125 men, and 278 women; mean age: 72.4 ± 6.9 years) in which the protocol of screening and decolonization of S. aureus nasal carriers was applied between January 2014 and December 2016. During this latter period patients were preoperatively screened and, if positive, treated with mupirocin nasal ointment and chlorhexidine soap, for 5 days prior to surgery. Results In the control group, 17 of 400 patients (4.2%) had a SSI, 8 (2%) of them caused by S. aureus and 9 (2.2%) by other microorganisms. In the intervention group 20.6% of patients had a positive S. aureus nasal swab and were treated according to the protocol. 5 of 403 patients (1.2%) in this group had a SSI, 1 (0.2%) due to S. aureus and 4 (1%) to other microorganisms. When comparing surgical-site infection (SSI) rates between the two groups, we found a statistically significant reduction in both global SSI (p = 0.009) and specifically S. aureus SSI (p = 0.02), in the intervention group. No decolonized S. aureus nasal carrier presented a SSI. Discussion In patients undergoing TKA a preoperative screening and decolonization protocol for S. aureus nasal carriers, using mupirocin nasal ointment and chlorhexidine soap, is an effective measure to reduce the rate of SSI caused by this microorganism. Level of Evidence Level III; Therapeutic Study.
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Impact of decolonization on methicillin-resistant Staphylococcus aureus transmission and infection in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2019; 40:1123-1127. [PMID: 31362800 DOI: 10.1017/ice.2019.217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The value of decolonization as a strategy for preventing methicillin-resistantStaphylococcus aureus (MRSA) in the neonatal intensive care unit (NICU) remains to be determined. OBJECTIVE After adding decolonization to further reduce MRSA transmission in our NICU, we conducted this retrospective review to evaluate its effectiveness. METHOD The review included patients who were admitted to our NICU between April 2015 and June 2018 and were eligible for decolonization including twice daily intranasal mupirocin and daily chlorhexidine gluconate bathing over 5 consecutive days. Patients were considered successfully decolonized if 3 subsequent MRSA screenings conducted at 1-week intervals were negative. The MRSA acquisition rate (AR) was calculated as hospital-acquired (HA) MRSA per 1,000 patient days (PD) and was used to measure the effectiveness of the decolonization. RESULTS Of the 151 MRSA patients being reviewed, 78 (51.6%) were HA-MRSA, resulting in an overall AR of 1.27 per 1,000 PD. Between April 2015 and February 2016, when only the decolonization was added, the AR was 2.38 per 1,000 PD. Between March 2016 and June 2018 after unit added a technician dedicated to the cleaning of reusable equipment, the AR decreased significantly to 0.92 per 1,000 PD (P < .05). Of the 78 patients who were started on the decolonization, 49 (62.8%) completed the protocol, 11 (14.1%) remained colonized, and 13 (16.7%) were recolonized prior to NICU discharge. CONCLUSION In a NICU with comprehensive MRSA prevention measures in place, enhancing the cleaning of reusable equipment, not decolonization, led to significant reduction of MRSA transmission.
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Oliveira CLDT, Elias FA, Ribacionka ADS, Picado CHF, Garcia FL. DOES TOPICAL USE OF GENTAMICIN REDUCE THE INFECTION RATE IN PRIMARY TOTAL HIP ARTHROPLASTY? ACTA ORTOPEDICA BRASILEIRA 2019; 27:197-201. [PMID: 31452619 PMCID: PMC6699383 DOI: 10.1590/1413-785220192704219177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine whether the topical use of gentamicin reduces periprosthetic joint infection rates in primary total hip arthroplasty (THA). METHODS We retrospectively evaluated two cohorts of patients who underwent primary THA in a university hospital, with a minimum of 1-year postoperative follow-up and full clinical, laboratory, and radiological documentation. Patients who underwent operation in the first 59 months of the study period (263 hips) received only intravenous cefazolin as antibiotic prophylaxis (Cef group), and those who underwent operation in the following 43 months (170 hips) received intravenous cefazolin plus topical gentamicin directly applied on the wound as antibiotic prophylaxis (Cef + Gen group). For the diagnosis of periprosthetic joint infection, we used the criteria of the Centers for Disease Control and Prevention. Data were analyzed using the Fisher exact test, and p values of <0.05 were considered significant. RESULTS Thirteen hips (4.9%) in the Cef group and eight hips (4.7%) in the Cef + Gen group presented periprosthetic joint infection. Statistical analysis revealed no difference between the infection rates (p = 1.0). CONCLUSION Topical gentamicin as used in this study did not reduce periprosthetic joint infection rates in primary THA. Level of Evidence III, Retrospective comparative study.
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Womble TN, King JD, Hamilton DH, Shrout M, Jacobs CA, Duncan ST. Greater Rates of Acute Kidney Injury in African American Total Knee Arthroplasty Patients. J Arthroplasty 2019; 34:1240-1243. [PMID: 30824293 PMCID: PMC6536310 DOI: 10.1016/j.arth.2019.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/07/2019] [Accepted: 01/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This retrospective study compared the change in serum creatinine between African American and Caucasian total knee arthroplasty (TKA) patients. The authors hypothesized that African Americans would demonstrate significantly greater change, and that a significantly greater proportion would demonstrate creatinine changes consistent with acute kidney injury (AKI). METHODS Primary TKAs performed at a single institution between July 2011 and June 2016 were identified: 1035 primary TKAs met inclusion and exclusion criteria (110 African American, 925 Caucasian, excluding Hispanic and Asian patients). None were excluded based on gender, age, body mass index, preoperative diagnosis, or comorbidities. All patients had preoperative and postoperative creatinine levels available in the electronic medical records. Each patient received the same preop and postop protocol for nonsteroidal anti-inflammatory drug use along with other drugs administered including anesthesia. All patients received 1 g of intravenous vancomycin with some patients additionally receiving 1 g of vancomycin powder administered locally at the end of surgery. All patients were controlled for fluid intake and blood loss, along with no patient receiving a transfusion or intravenous contrast. Patient demographics and preoperative/postoperative serum creatinine were recorded and then analyzed for presence of AKI (≥0.3 mg/dL). Preoperative/postoperative serum creatinine concentrations were compared between African American and Caucasian patients using 2 × 2 repeated measures analysis of variance. Prevalence of patients in each group demonstrating AKI was calculated using Fisher's exact test. RESULTS African American patients had significantly greater serum creatinine preoperatively (1.00 ± 0.26 vs 0.90 ± 0.22, P < .001) and a significantly greater increase postoperatively (0.10 vs 0.03, P < .001). A significantly greater number of African American patients demonstrated AKI (10.9% vs 5.1%, P = .03). Furthermore, a significantly greater number of African American patients stayed in the hospital an additional 2 or more days for renal issues (2.7% vs 0.4%, P = .03). CONCLUSION Altered renal function was significantly more common in African American TKA patients. Future studies are necessary to determine if tailoring anti-inflammatories, perioperative medications, and preoperative comorbidities reduce the risk of renal injury and/or a longer hospital stay for this subset of patients.
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Åkesson P, Chen AF, Deirmengian GK, Geary M, Quevedo MS, Sousa R, Springer BD, Wang Q. General Assembly, Prevention, Risk Mitigation, Local Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S49-S53. [PMID: 30360980 DOI: 10.1016/j.arth.2018.09.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
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.
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Affiliation(s)
- V K Alamanda
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - B D Springer
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA and OrthoCarolina Hip and Knee Center, Charlotte, North Carolina, USA
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Inabathula A, Dilley JE, Ziemba-Davis M, Warth LC, Azzam KA, Ireland PH, Meneghini RM. Extended Oral Antibiotic Prophylaxis in High-Risk Patients Substantially Reduces Primary Total Hip and Knee Arthroplasty 90-Day Infection Rate. J Bone Joint Surg Am 2018; 100:2103-2109. [PMID: 30562290 DOI: 10.2106/jbjs.17.01485] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total joint arthroplasty (TJA) episodic payment models shift risk and cost of periprosthetic joint infection (PJI) to surgeons and hospitals, causing some to avoid treating high-risk patients. Furthermore, there are little data to support optimization of host factors preoperatively to decrease PJI, and recent literature supports using extended antibiotic prophylaxis following reimplantation TJA. The purpose of this study was to evaluate whether extended oral antibiotic prophylaxis minimized PJI after primary TJA in high-risk patients. METHODS A retrospective cohort study was performed of 2,181 primary total knee arthroplasties (TKAs) and primary total hip arthroplasties (THAs) carried out from 2011 through 2016 at a suburban academic hospital with modern perioperative and infection-prevention protocols. Beginning in January 2015, extended oral antibiotic prophylaxis for 7 days after discharge was implemented for patients at high risk for PJI. The percentages of patients diagnosed with PJI within 90 days were identified and compared between groups that did and did not receive extended oral antibiotic prophylaxis, with p ≤ 0.05 indicating significance. RESULTS The 90-day infection rates were 1.0% and 2.2% after the TKAs and THAs, respectively. High-risk patients without extended antibiotic prophylaxis were 4.9 (p = 0.009) and 4.0 (p = 0.037) times more likely to develop PJI after TKA and THA, respectively, than high-risk patients with extended antibiotic prophylaxis. CONCLUSIONS Extended postoperative antibiotic prophylaxis led to a statistically significant and clinically meaningful reduction in the 90-day infection rate of selected patients at high risk for infection. We encourage further study and deliberation prior to adoption of a protocol involving extended oral antibiotic prophylaxis after high-risk TJA, with the benefits weighed appropriately against potential adverse consequences such as increasing the development of antimicrobial resistance. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Julian E Dilley
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Lucian C Warth
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Khalid A Azzam
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip H Ireland
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - R Michael Meneghini
- Indiana University Health Orthopedics, Indianapolis, Indiana.,Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Li ZL, Hou YF, Zhang BQ, Chen YF, Wang Q, Wang K, Chen ZY, Li XW, Lin JH. Identifying Common Pathogens in Periprosthetic Joint Infection and Testing Drug-resistance Rate for Different Antibiotics: A Prospective, Single Center Study in Beijing. Orthop Surg 2018; 10:235-240. [PMID: 30152610 DOI: 10.1111/os.12394] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/05/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The aim of this study is to identify the common microorganisms causing PJI as well as the drug-resistant spectrum for each microorganism, to help orthopaedic surgeons to choose appropriate antibiotics. METHOD One hundred and sixty patients who suffered from failure of primary or revision total hip or knee arthroplasty for different reasons were prospectively recruited. These patients underwent revision or re-revision total hip or knee arthroplasty in our institution between August 2013 to August 2016. The details of patients' medical history and comprehensive physical examination, as well as demographic data were recorded precisely. Routine blood test results, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), high sensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6) levels, and synovial leukocyte counts were collected. Additionally, aspiration was conducted during surgery to avoid pollution unless when PJI was strongly suspected, in which case, joint puncture and aspiration were conducted before surgery. Intraoperatively, the implant-surrounding tissue and the prosthesis were collected under aseptic conditions. Postoperatively, the prosthesis, implant-surrounding tissue and synovium were sent to the laboratory immediately. The sonicate extraction (the prosthesis was sent for ultrasound sonication first), implant surrounding tissue and synovium were sent for microbiologic culture, and the implant-surrounding tissue was also sent for pathological examination. The isolated bacteria strains and drug-resistance rates for each pathogen for different antibiotics were presented. RESULTS There were 59 PJI cases in the infectious group and 101 cases in the non-infectious group (PJI is diagnosed according to the diagnosing criteria from the Workgroup of the Musculoskeletal Infection Society). Of 69 strains of pathogens isolated, Gram-positive bacterium is the most common pathogenic bacteria causing PJI (60, 86.96%). Staphylococcus epidermidis and Staphylococcus aureus played an important role as well, followed by Gram-negative bacteria (8, 11.59%) and fungus (1, 1.45%). Penicillin (78.57%), erythromycin (66.67%) and clindamycin (44.74%) showed high antibiotic resistance rate. In addition, the second-generation cephalosporin, usually as the prophylactic antibiotic, resistance rate was high (20%) as well. Fortunately, no vancomycin-resistant bacteria were discovered in the current study. CONCLUSION This study provides some information on the most common pathogens in our institution and the selection of antibiotics in the perioperative period in northern China. Cefuroxime and clindamycin might not be appropriate for use as prophylactic antibiotics in revision total knee or hip arthroplasty. Vancomycin is ideal for empiric antibiotic use in suspected PJI cases because of the low drug-resistance rate.
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Affiliation(s)
- Zhang-Lai Li
- Department of Orthopedics, Fuzhou Second Hospital of Xiamen University, Fuzhou, China.,Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Yun-Fei Hou
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Bao-Qing Zhang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China.,Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Yi-Fan Chen
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Kai Wang
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Zhao-Yu Chen
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Xiao-Wei Li
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
| | - Jian-Hao Lin
- Arthritis Clinic and Research Center, Peking University People's Hospital, Beijing, China
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Hijas-Gómez AI, Lucas WC, Checa-García A, Martínez-Martín J, Fahandezh-Saddi H, Gil-de-Miguel Á, Durán-Poveda M, Rodríguez-Caravaca G. Surgical site infection incidence and risk factors in knee arthroplasty: A 9-year prospective cohort study at a university teaching hospital in Spain. Am J Infect Control 2018; 46:1335-1340. [PMID: 30025619 DOI: 10.1016/j.ajic.2018.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is one of the complications posed by knee replacement surgery. Hospital-based infection surveillance systems may provide indicators of improvement and allow the characterization of risk factors critical to reduce infection. The aims of this study were to compare the incidence of SSI in our center with rates in the Madrid Region, Spain, and the United States, and to evaluate any possible SSI-related risk factor in knee replacement surgery. METHODS All patients who underwent knee replacement surgery at a tertiary hospital in 2008-2016 were included. SSI was defined according to Centers for Disease Control and Prevention criteria. Infection rate was calculated. The association between risk factors and SSI incidence was assessed by reference to odds ratio (OR) with multivariate analysis. RESULTS The study population (n = 1969) had a global SSI risk of 1.0%. We found a declining trend in the follow-up period, from an SSI risk of 1.8% in 2009 to 0.4% in 2016. Independent risk factors included hair removal (OR: 3.09, 95% confidence interval [CI]: 1.27-7.50) and National Healthcare Safety Network risk index ≥ 2 (OR: 9.37, 95% CI: 2.90-30.26). CONCLUSION This study identified risk factors that showed the necessity to strictly comply with wound decontamination and patient preparation protocols, reduce surgery duration, and identify patients who require comprehensive monitoring.
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Affiliation(s)
- Ana Isabel Hijas-Gómez
- Department of Preventive Medicine and Public Health. University Hospital Fundación Alcorcón, Madrid, Spain; Health Technology Assessment Agency (AETS), Carlos III Institute of Health, Madrid, Spain.
| | - Warren Covelé Lucas
- Department of Preventive Medicine and Public Health. University Hospital Fundación Alcorcón, Madrid, Spain; Department of Sport, Recreation and Exercise Science, University of the Western Cape, Cape Town, South Africa
| | - Antonio Checa-García
- Department of Orthopedic Surgery and Traumatology, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Javier Martínez-Martín
- Department of Orthopedic Surgery and Traumatology, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Homid Fahandezh-Saddi
- Department of Orthopedic Surgery and Traumatology, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Ángel Gil-de-Miguel
- Department of Preventive Medicine and Public Health, University Rey Juan Carlos, Madrid, Spain
| | - Manuel Durán-Poveda
- General and Endocrine Surgery Department, University Rey Juan Carlos, Madrid, Spain
| | - Gil Rodríguez-Caravaca
- Department of Preventive Medicine and Public Health. University Hospital Fundación Alcorcón, Madrid, Spain; Department of Preventive Medicine and Public Health, University Rey Juan Carlos, Madrid, Spain
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36
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Burger JR, Hansen BJ, Leary EV, Aggarwal A, Keeney JA. Dual-Agent Antibiotic Prophylaxis Using a Single Preoperative Vancomycin Dose Effectively Reduces Prosthetic Joint Infection Rates With Minimal Renal Toxicity Risk. J Arthroplasty 2018; 33:S213-S218. [PMID: 29656981 DOI: 10.1016/j.arth.2018.03.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We performed this study to compare prosthetic joint infection (PJI) and renal toxicity rates following hip and knee total joint arthroplasty (TJA) when a first-generation cephalosporin was administered either alone or in combination with a single preoperative vancomycin dose, whether vancomycin administration timing potentially influenced dual-antibiotic PJI prophylaxis approach effectiveness, and whether single-dose vancomycin use increased risk of renal impairment. METHODS This was a retrospective study of 1997 consecutive primary TJAs (1871 patients) treated with cefazolin alone (1044 TJAs) or cefazolin with single-dose vancomycin (953 TJAs). The vancomycin group included 476 TJAs (450 patients) with infusion started at least 45 minutes before the skin incision and 477 TJAs (464 patients) with infusion started less than 45 minutes before the skin incision. RESULTS The addition of a single dose of vancomycin did not significantly reduce PJI rates when compared with cefazolin alone (1.6% vs 2.1%, P = .32). However, the PJI rate was significantly lower following primary TJA when vancomycin administration was initiated at least 45 minutes before incision (0.2%) when compared with other TJA procedures performed using cefazolin and vancomycin (2.9%, P < .01) or cefazolin alone (2.1%, P < .01). We observed no difference in renal toxicity between treatment groups. CONCLUSION In our institution, the addition of vancomycin to cefazolin at least 45 minutes before incision reduced PJI infection rates in primary hip and knee TJA with a low risk of renal impairment.
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Affiliation(s)
- John R Burger
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Benjamin J Hansen
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Emily V Leary
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ajay Aggarwal
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James A Keeney
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Rieser GR, Moskal JT. Cost Efficacy of Methicillin-Resistant Staphylococcus aureus Decolonization With Intranasal Povidone-Iodine. J Arthroplasty 2018; 33:1652-1655. [PMID: 29506927 DOI: 10.1016/j.arth.2018.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- G Ryan Rieser
- Virginia Tech - Carilion Clinic, Institute for Orthopaedics and Neurosciences, Roanoke, VA
| | - Joseph T Moskal
- Virginia Tech - Carilion Clinic, Institute for Orthopaedics and Neurosciences, Roanoke, VA
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38
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Profilaxia com descolonização nasal em pacientes submetidos a artroplastia total de joelho e quadril: revisão sistemática com metanálise. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Sadigursky D, Pires HS, Rios SAC, Rodrigues Filho FLB, Queiroz GCD, Azi ML. Prophylaxis with nasal decolonization in patients submitted to total knee and hip arthroplasty: systematic review and meta-analysis. Rev Bras Ortop 2017; 52:631-637. [PMID: 29234644 PMCID: PMC5720853 DOI: 10.1016/j.rboe.2016.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/28/2016] [Indexed: 12/28/2022] Open
Abstract
Despite the evolution of the total knee and hip arthroplasty surgery, high postoperative complication rates in the short and long term still persist. Infection is one of the most challenging complications; due to its gravity and treatment difficulties, prophylaxis protocols have been created to decrease its incidence. The objective of this study was to evaluate the impact of the prophylaxis protocol for methicillin-resistant Staphylococcus aureus decolonization of the nares in patients previously identified by swab cultures, who were to be submitted to a total joint arthroplasty. A systematic review with meta-analysis was conducted, following the PRISMA-2015 protocol, using the descriptors: "arthroplasty" and "nasal decolonization," or "joint arthroplasty" and "decolonization," or "joint arthroplasty" and "nasal decolonization," for final selection of four observational studies from 79 references identified. This study included a total sample of 10,179 patients, divided in two groups: the control group (4788 patients) and intervention group (5391 patients). It was observed that the intervention group, in which prophylaxis with nasal decolonization was used, 59 (1.09%) of the patients developed a surgical site infection, while in the control group there were 86 cases of surgical site infection (1.79%). This trend repeated itself in all articles, showing no publication biases, forming a homogeneous sample. The use of a prophylaxis protocol for decolonization of methicillin-resistant Staphylococcus aureus, reduced surgical site infection cases by approximately 39%.
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Chopra R, Shaikh S, Chatzinoff Y, Munaweera I, Cheng B, Daly SM, Xi Y, Bing C, Burns D, Greenberg DE. Employing high-frequency alternating magnetic fields for the non-invasive treatment of prosthetic joint infections. Sci Rep 2017; 7:7520. [PMID: 28790407 PMCID: PMC5548742 DOI: 10.1038/s41598-017-07321-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/29/2017] [Indexed: 11/16/2022] Open
Abstract
Treatment of prosthetic joint infection (PJI) usually requires surgical replacement of the infected joint and weeks of antibiotic therapy, due to the formation of biofilm. We introduce a non-invasive method for thermal destruction of biofilm on metallic implants using high-frequency (>100 kHz) alternating magnetic fields (AMF). In vitro investigations demonstrate a >5-log reduction in bacterial counts after 5 minutes of AMF exposure. Confocal and scanning electron microscopy confirm removal of biofilm matrix components within 1 minute of AMF exposure, and combination studies of antibiotics and AMF demonstrate a 5-log increase in the sensitivity of Pseudomonas aeruginosa to ciprofloxacin. Finite element analysis (FEA) simulations demonstrate that intermittent AMF exposures can achieve uniform surface heating of a prosthetic knee joint. In vivo studies confirm thermal damage is confined to a localized region (<2 mm) around the implant, and safety can be achieved using acoustic monitoring for the presence of surface boiling. These initial studies support the hypothesis that AMF exposures can eradicate biofilm on metal implants, and may enhance the effectiveness of conventional antibiotics.
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Affiliation(s)
- Rajiv Chopra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA.
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Sumbul Shaikh
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yonatan Chatzinoff
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Imalka Munaweera
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Bingbing Cheng
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Seth M Daly
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Chenchen Bing
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Dennis Burns
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - David E Greenberg
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Microbiology, UT Southwestern Medical Center, Dallas, TX, USA
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Shohat N, Parvizi J. Prevention of Periprosthetic Joint Infection: Examining the Recent Guidelines. J Arthroplasty 2017; 32:2040-2046. [PMID: 28366315 DOI: 10.1016/j.arth.2017.02.072] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The global rise in infectious disease has led the Center for Disease Control and Prevention and the World Health Organization to release new guidelines for the prevention of surgical site infection. METHODS In this article, we summarize current recommendations based on level of evidence, review unresolved and unaddressed issues, and supplement them with new literature. RESULTS Although the guidelines discuss major issues in reducing surgical site infection, many questions remain unanswered. CONCLUSION These guidelines will hopefully help in setting a standard of care based on best evidence available and focus investigators on areas where evidence is lacking.
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Affiliation(s)
- Noam Shohat
- Tel Aviv University, Tel Aviv, Israel; Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Loewen K, Schreiber Y, Kirlew M, Bocking N, Kelly L. Community-associated methicillin-resistant Staphylococcus aureus infection: Literature review and clinical update. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:512-520. [PMID: 28701438 PMCID: PMC5507223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To provide information on the prevalence and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the distinction between community-associated MRSA and health care-associated MRSA. QUALITY OF EVIDENCE The MEDLINE and EMBASE databases were searched from 2005 to 2016. Epidemiologic studies were summarized and the relevant treatment literature was based on level I evidence. MAIN MESSAGE The incidence of community-associated MRSA infection is rising. Certain populations, including indigenous Canadians and homeless populations, are particularly affected. Community-associated MRSA can be distinguished from health care-associated MRSA based on genetic, epidemiologic, or microbiological profiles. It retains susceptibility to some oral agents including trimethoprim-sulfamethoxazole, clindamycin, and tetracyclines. Community-associated MRSA typically presents as purulent skin and soft tissue infection, but invasive infection occurs and can lead to severe, complicated disease. Treatment choices and the need for empiric MRSA coverage are influenced by the type and severity of infection. CONCLUSION Community-associated MRSA is a common cause of skin and soft tissue infections and might be common in populations where overcrowding and limited access to clean water exist.
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Affiliation(s)
- Kassandra Loewen
- Research intern in the Anishinaabe Bimaadiziwin Research Program in Sioux Lookout, Ont
| | - Yoko Schreiber
- Assistant Professor at the University of Ottawa in the Ottawa Hospital in Ontario, Clinical Investigator in the Ottawa Hospital Research Institute, and a visiting faculty member at the Northern Ontario School of Medicine in Sioux Lookout
| | - Mike Kirlew
- Assistant Professor at the Northern Ontario School of Medicine and a community physician in Sioux Lookout
| | - Natalie Bocking
- Public health physician in the Sioux Lookout First Nations Health Authority
| | - Len Kelly
- Research consultant for the Anishinaabe Bimaadiziwin Research Program.
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Ratto N, Arrigoni C, Rosso F, Bruzzone M, Dettoni F, Bonasia DE, Rossi R. Total knee arthroplasty and infection: how surgeons can reduce the risks. EFORT Open Rev 2017; 1:339-344. [PMID: 28461965 PMCID: PMC5367521 DOI: 10.1302/2058-5241.1.000032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Total joint arthroplasty (TJA) is one of the most common orthopaedic procedures. Nevertheless, several complications can lead to implant failure. Peri-prosthetic joint infections (PJI) certainly represent a significant challenge in TJA, constituting a major cause of prosthetic revision. The surgeon may have an important role in reducing the PJI rate by limiting the impact of significant risk factors associated to either the patient, the operative environment or the post-operative care. In the pre-operative period, several preventive measures may be adopted to manage reversible medical comorbidities. Other recognised pre-operative risk factors are urinary tract infections, intra-articular corticosteroid injections and nasal colonisation with Staphylococcus (S.) aureus, particularly the methicillin-resistant strain (MRSA). In the intra-operative setting, protective measures for PJI include antibiotic prophylaxis, surgical-site antisepsis and use of pre-admission chlorhexidine washing and pulsed lavage during surgery. In this setting, the use of plastic adhesive drapes and sterile stockinette, as well as using personal protection systems, do not clearly reduce the risk of infection. On the contrary, using sterile theatre light handles and splash basins as well as an increased traffic in the operating room are all associated with an increased risk for PJI. In the post-operative period, other infections causing transient bacteraemia, blood transfusion and poor wound care are considered as risk factors for PJI.
Cite this article: Ratto N, Arrigoni C, Rosso F, Bruzzone M, Dettoni F, Bonasia DE, Rossi R. Total knee arthroplasty and infection: how surgeons can reduce the risks. EFORT Open Rev 2016;1: 339-344 DOI: 10.1302/2058-5241.1.000032.
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Affiliation(s)
| | | | - Federica Rosso
- AO Mauriziano Umberto I, Department of Orthopedics and Traumatology, Torino, Italy
| | - Matteo Bruzzone
- AO Mauriziano Umberto I, Department of Orthopedics and Traumatology, Torino, Italy
| | - Federico Dettoni
- AO Mauriziano Umberto I, Department of Orthopedics and Traumatology, Torino, Italy
| | | | - Roberto Rossi
- AO Mauriziano Umberto I, Department of Orthopedics and Traumatology, Torino, Italy
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Chirca I, Marculescu C. Prevention of Infection in Orthopedic Prosthetic Surgery. Infect Dis Clin North Am 2017; 31:253-263. [PMID: 28292539 DOI: 10.1016/j.idc.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.
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Affiliation(s)
- Ioana Chirca
- Department of infectious Diseases, University Hospital, 1350 Walton Way, Augusta, GA 30909, USA
| | - Camelia Marculescu
- Division of Infectious Diseases, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA.
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Ma N, Cameron A, Tivey D, Grae N, Roberts S, Morris A. Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery. ANZ J Surg 2017; 87:239-246. [PMID: 28190291 DOI: 10.1111/ans.13879] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ning Ma
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Alun Cameron
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - David Tivey
- Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Nikki Grae
- New Zealand Health Quality & Safety Commission, Wellington, New Zealand
| | - Sally Roberts
- Auckland District Health Board, Auckland, New Zealand
| | - Arthur Morris
- Auckland District Health Board, Auckland, New Zealand
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Abstract
Host optimization, reduction of bacteria, and establishing proper wound environment in the preoperative, intraoperative, and postoperative periods are the traditional cornerstones of infection prevention. Most institutions have standardized a systems approach to reduce the incidence of surgical site infections. Typically, these systems-based approaches promote protocols for hand and environmental hygiene, patients risk assessment and screening, surgical delays for identifiable and modifiable risk factors, infection surveillance, antibiotic stewardship programs, communication/coordination of care, physician 360° reporting, and unit-based safety programs. Despite the institution of these prevention efforts, there remains controversy about the efficacy and cost-effectiveness of a number of these approaches.
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47
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Affiliation(s)
- James T Ninomiya
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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48
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Editor's Spotlight/Take 5: Addition of Vancomycin to Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint Arthroplasty. Clin Orthop Relat Res 2015; 473:2193-6. [PMID: 25910778 PMCID: PMC4457772 DOI: 10.1007/s11999-015-4318-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/14/2015] [Indexed: 01/31/2023]
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