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Wu Y, Xiang X, Ma Y. The effect of different preventive strategies during total joint arthroplasty on periprosthetic joint infection: a network meta-analysis. J Orthop Surg Res 2024; 19:360. [PMID: 38890743 PMCID: PMC11184793 DOI: 10.1186/s13018-024-04738-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection after total joint arthroplasty has a large incidence, and it may often require two or more stages of revision, placing an additional burden on clinicians and patients. The purpose of this network meta-analysis is to evaluate the effect of four different preventive strategies during total joint arthroplasty on the prevention of periprosthetic joint infection. METHODS The study protocol was registered at PROSPERO (CRD: 42,023,448,868), and the literature search databases included Web of Science, PubMed, OVID Cochrane Central Register of Controlled Trials, OVID EMBASE, and OVID MEDLINE (R) ALL that met the requirements. The network meta-analysis included randomized controlled trials, retrospective cohort studies and prospective cohort studies with the outcome of periprosthetic joint infection. The gemtc R package was applied to perform the network meta-analysis to evaluate the relative results of different preventive strategies. RESULTS This network meta-analysis study included a total of 38 articles with 4 preventive strategies and negative controls. No improvement was observed in antibiotic-loaded bone cement compared with negative controls. Chlorhexidine showed the highest probability of delivering the best preventive effect, and povidone iodine had the second highest probability. Although vancomycin ranked after chlorhexidine and povidone iodine, it still showed a significant difference compared with negative controls. In addition, the incidence after applying chlorhexidine was significantly lower than that after applying negative controls and vancomycin. In the heterogeneity test between direct and indirect evidence, there was no apparent heterogeneity between them. CONCLUSION The study indicated that chlorhexidine, povidone iodine and vancomycin showed significant efficacy in preventing periprosthetic joint infection after total joint arthroplasty, while antibiotic-loaded bone cement did not. Therefore, more high-quality randomized controlled trials are needed to verify the results above.
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Affiliation(s)
- Yongtao Wu
- Department of Pediatrics, West China Second University Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Xinni Xiang
- Department of Pediatrics, West China Second University Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yimei Ma
- Department of Pediatrics, West China Second University Hospital, West China School of Medicine, Sichuan University, Chengdu, 610041, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China.
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Nye AK, Thieman Mankin KM. Small animal patient preoperative preparation: a review of common antiseptics, comparison studies, and resistance. Front Vet Sci 2024; 11:1374826. [PMID: 38605919 PMCID: PMC11007076 DOI: 10.3389/fvets.2024.1374826] [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: 01/22/2024] [Accepted: 03/19/2024] [Indexed: 04/13/2024] Open
Abstract
This review aims to describe commonly used antiseptics in veterinary medicine including their mechanism of action, spectrum of activity, potential adverse effects, and application techniques. Additionally, it provides a review of the veterinary literature comparing antiseptics, a discussion of effectiveness and efficacy studies, and the potential for increased resistance to biocides and antimicrobials. This review concludes that appropriate selection and use is necessary to prevent the occurrence of surgical site infections, adverse effects, and potential for increasing resistance to antimicrobials. Continued research is needed to fill gaps in the current knowledge such as optimal preparation procedures for various surgical sites, standardization of efficacy and effectiveness testing, and the clinical impact of decreased susceptibility to chlorhexidine and other antiseptics.
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Affiliation(s)
| | - Kelley M. Thieman Mankin
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, United States
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Zhang J, Xia C, Zhang J, Wang S, Li J. Sequential pre-disinfection with chlorhexidine and alcohol reduces periprosthetic joint infection after primary knee arthroplasty: A case-control study. Medicine (Baltimore) 2023; 102:e36101. [PMID: 38013333 PMCID: PMC10681569 DOI: 10.1097/md.0000000000036101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023] Open
Abstract
A retrospective case-control study was conducted to assess whether patients who underwent sequential preoperative disinfection before primary total knee or unicompartmental arthroplasty had a lower rate of postoperative infection than those who did not. In our study, 1025 patients who underwent total knee or unicompartmental arthroplasty at 2 medical centers between September 1, 2020, and August 31, 2021, were enrolled. Statistical analysis was performed for 976 cases, including 966 and 10 uninfected and infected cases, respectively. All patients were followed up for 1-year. Data analysis was performed by binary logistic regression and adjusted for 2 confounding factors: general anesthesia and rheumatoid arthritis. IBM SPSS for Windows (version 25.0; IBM Co., Armonk, NY) software was used to perform all statistical analyses. During the study period, of the 976 patients, 10 cases of infections were detected. Sequential pre-disinfection (adjusted odds ratio 0.14, 95% confidence interval: 0.03-0.54, P = .005) could reduce the incidence of infection. Based on the results of this study, bathing the whole lower limb with 2% chlorhexidine on the night before surgery followed by 70% alcohol application 1 hour before surgery is effective for preventing periprosthetic joint infection during primary total knee or unicompartmental arthroplasty.
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Affiliation(s)
- Jinhao Zhang
- Department of Orthopedic Surgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, China
| | - Chenjie Xia
- Department of Orthopedic Surgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, China
| | - Junhui Zhang
- Department of Orthopedic Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Shicheng Wang
- Department of Orthopedic Surgery, Ningbo No. 6 Hospital, Ningbo, China
| | - Jin Li
- Department of Orthopedic Surgery, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, China
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Abstract
BACKGROUND Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections. METHODS A PubMed search was performed to update the evidence on skin antiseptic products and practices. RESULTS Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs. CONCLUSIONS Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.
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Stopping prehospital chlorhexidine skin wash does not increase wound morbidity after incisional hernia repair: results of a 4-year quality improvement initiative. Hernia 2022; 27:575-582. [DOI: 10.1007/s10029-022-02722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/13/2022] [Indexed: 11/27/2022]
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Edmiston CE, Leaper DJ. Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review. Surg Infect (Larchmt) 2022; 23:645-655. [PMID: 35925775 DOI: 10.1089/sur.2022.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.
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Affiliation(s)
- Charles E Edmiston
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin USA
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Use of a Smart-Phone Mobile Application is Associated With Improved Compliance and Reduced Length of Stay in Patients Undergoing Primary Total Joint Arthroplasty of the Hip and Knee. J Arthroplasty 2022; 37:1534-1540. [PMID: 35341922 DOI: 10.1016/j.arth.2022.03.068] [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: 01/04/2022] [Revised: 02/19/2022] [Accepted: 03/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patient compliance with perioperative protocols is paramount to improving outcomes and reducing adverse events in total joint arthroplasty (TJA) of the hip and knee. Given the widespread use of smartphones, mobile applications (MAs) may present an opportunity to improve outcomes in TJA. We aim to determine whether the use of a mobile application platform improves compliance with standardized pre-operative protocols and outcomes in TJA. METHODS A non-randomized, prospective cohort study was conducted in adult patients undergoing primary elective TJA to determine whether the use of an MA with timed reminders starting 5 days pre-operatively, to perform a chlorhexidine gluconate (CHG) shower and oral hydration protocol improves compliance with these protocols. OUTCOME MEASURES compliance, length of stay (LOS), surgical site infection (SSI), 90-day readmission. RESULTS App-users had increased adherence to the hydration protocol (odds ratio [OR] = 3.17 [95% confidence interval {CI} = 1.42, 7.09: P = .003]). App-use was associated with shorter LOS (Median Interquartile ranges [IQR] 2.0 days [1.0, 2.0 days]) for App-users vs 2.0 days ([1.0, 3.0] for non-App users, P = .031), younger age, (63.3 vs 67.9 years, P = .0001), Caucasian race (OR = 3.32 [95% CI = 1.59, 6.94 P = .0009]) and male gender (48.2% vs 35.0%, P = .02). There was no difference in adherence to chlorhexidine gluconate (CHG), readmission, or surgical site infection (SSI) (2.2% App-users vs 2.9% non-App users; P = .74). CONCLUSION Use of a mobile application was associated with increased compliance with a hydration protocol and reduced LOS. App-users were more likely to be younger, male and Caucasian. These disparities may reflect inequity of access to the requisite technology and warrant further study.
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Wouters D, Cavallaro G, Jensen KK, East B, Jíšová B, Jorgensen LN, López-Cano M, Rodrigues-Gonçalves V, Stabilini C, Berrevoet F. The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery. Front Surg 2022; 9:847279. [PMID: 35910469 PMCID: PMC9326087 DOI: 10.3389/fsurg.2022.847279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair. Methods A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible. Results From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants. Conclusion This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.
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Affiliation(s)
- D. Wouters
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - G. Cavallaro
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - Kristian K. Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - B. East
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - B. Jíšová
- 3rd Department of Surgery and 1st Medical Faculty of Charles University, Motol University Hospital, Prague, Czech Republic
| | - L. N. Jorgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - M. López-Cano
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - V. Rodrigues-Gonçalves
- Abdominal Wall Surgery Unit, Department of General Surgery, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C. Stabilini
- Department of Surgery, University of Genoa, Genoa, Italy
- European Hernia Society, Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - F. Berrevoet
- Department for General and HPB Surgery and Liver Transplantation, University Hospital Gent, Gent, Belgium
- Correspondence: Frederik Berrevoet
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Forget V, Azzam O, Khouri C, Landelle C. What is the benefit of preoperative washing with chlorhexidine gluconate-impregnated cloths on the incidence of surgical site infections? A systematic review and meta-analysis. Infect Dis Now 2022; 52:185-192. [DOI: 10.1016/j.idnow.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/27/2022] [Indexed: 11/30/2022]
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Gómez-Barrena E, Warren T, Walker I, Jain N, Kort N, Loubignac F, Newman S, Perka C, Spinarelli A, Whitehouse MR, Zagra L, De la Torre BJ. Prevention of Periprosthetic Joint Infection in Total Hip and Knee Replacement: One European Consensus. J Clin Med 2022; 11:jcm11020381. [PMID: 35054075 PMCID: PMC8781876 DOI: 10.3390/jcm11020381] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/08/2022] [Accepted: 01/11/2022] [Indexed: 01/09/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a devastating complication in total hip and knee replacement. Its prevention is key to decrease the incidence and avoid some consequences that seriously impact patients and health systems. In view of the variety of recommendations and guidelines, we decided to conduct an expert, peer-reviewed European consensus analysis about the pre-, intra-, and postoperative prevention of PJI. A multinational group of practicing orthopedic experts developed a series of 47 consensus statements in 6 main groups of intervention, and a 2-stage Delphi approach was launched with a threshold for agreement at 75% and for very high agreement at more than 90%. A total of 306 orthopedic surgeon responses were gathered from 9 countries. Consensus was reached for 42/47 statements, 31/47 of which achieved a very high consensus. Many preoperative actions gathered strong consensus, although areas like the use of alcoholic chlorhexidine or the timing of hair removal did not attain strong consensus, despite available evidence. Intra- and postoperative actions showed more variability regarding incise drapes, skin suturing techniques, and wound follow-up. This study confirms an important consensus among orthopedic surgeons across Europe in many areas well known to contribute to the prevention of PJI; however, there are still grounds for improvement.
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Affiliation(s)
- Enrique Gómez-Barrena
- Department of Orthopaedic Surgery, Hospital La Paz, Autónoma University of Madrid, 28046 Madrid, Spain
- Correspondence: ; Tel.: +34-917277085
| | - Timothy Warren
- Triducive Ltd., Tunbridge Wells TN1 1NU, UK; (T.W.); (I.W.)
| | - Ian Walker
- Triducive Ltd., Tunbridge Wells TN1 1NU, UK; (T.W.); (I.W.)
| | - Neil Jain
- Department of Orthopaedic Surgery, Pennine Acute Hospitals NHS Trust, Manchester M8 5RB, UK;
| | - Nanne Kort
- CortoClinics, 5482 Schijndel, The Netherlands;
| | | | | | - Carsten Perka
- Department of Orthopaedic Surgery, Charité Hospital Universitätsmedizin, 10117 Berlin, Germany;
| | - Antonio Spinarelli
- UOC Ortopedia e Traumatologia, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Università degli Studi di Bari “Aldo Moro”, 70121 Bari, Italy;
| | - Michael R. Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol BS8 1TH, UK;
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol BS8 1TH, UK
| | - Luigi Zagra
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy;
| | - Basilio J. De la Torre
- Department of Orthopaedic Surgery, Hospital Ramón y Cajal, University of Alcalá, 28034 Madrid, Spain;
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Lawrie CM, Kazarian GS, Barrack T, Nunley RM, Barrack RL. Intra-articular administration of vancomycin and tobramycin during primary cementless total knee arthroplasty : determination of intra-articular and serum elution profiles. Bone Joint J 2021; 103-B:1702-1708. [PMID: 34719272 DOI: 10.1302/0301-620x.103b11.bjj-2020-2453.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Intra-articular administration of antibiotics during primary total knee arthroplasty (TKA) may represent a safe, cost-effective strategy to reduce the risk of acute periprosthetic joint infection (PJI). Vancomycin with an aminoglycoside provides antimicrobial cover for most organisms isolated from acute PJI after TKA. However, the intra-articular doses required to achieve sustained therapeutic intra-articular levels while remaining below toxic serum levels is unknown. The purpose of this study is to determine the intra-articular and serum levels of vancomycin and tobramycin over the first 24 hours postoperatively after intra-articular administration in primary cementless TKA. METHODS A prospective cohort study was performed. Patients were excluded if they had poor renal function, known allergic reaction to vancomycin or tobramycin, received intravenous vancomycin, or were scheduled for same-day discharge. All patients received 600 mg tobramycin and 1 g of vancomycin powder suspended in 25 cc of normal saline and injected into the joint after closure of the arthrotomy. Serum from peripheral venous blood and drain fluid samples were collected at one, four, and 24 hours postoperatively. All concentrations are reported in µg per ml. RESULTS A total of 22 patients were included in final analysis. At one, four, and 24 hours postoperatively, mean (95% confidence interval (CI)) serum concentrations were 2.4 (0.7 to 4.1), 5.0 (3.1 to 6.9), and 4.8 (2.8 to 6.9) for vancomycin and 4.9 (3.4 to 6.3), 7.0 (5.8 to 8.2), and 1.3 (0.8 to 1.8) for tobramycin; intra-articular concentrations were 1,900.6 (1,492.5 to 2,308.8), 717.9 (485.5 to 950.3), and 162.2 (20.5 to 304.0) for vancomycin and 2,105.3 (1,389.9 to 2,820.6), 403.2 (266.6 to 539.7), and 98.8 (0 to 206.5) for tobramycin. CONCLUSION Intra-articular administration of 1 g of vancomycin and 600 mg of tobramycin as a solution after closure of the arthrotomy in primary cementless TKA achieves therapeutic intra-articular concentrations over the first 24 hours postoperatively and does not reach sustained toxic levels in peripheral blood. Cite this article: Bone Joint J 2021;103-B(11):1702-1708.
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Affiliation(s)
- Charles Murray Lawrie
- Miami Orthopedics and Sports Medicine Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Gregory S Kazarian
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill-Cornell Medical School, New York, New York, USA
| | - Toby Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
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Bartsch SM, Wong KF, Mueller LE, Gussin GM, McKinnell JA, Tjoa T, Wedlock PT, He J, Chang J, Gohil SK, Miller LG, Huang SS, Lee BY. Modeling Interventions to Reduce the Spread of Multidrug-Resistant Organisms Between Health Care Facilities in a Region. JAMA Netw Open 2021; 4:e2119212. [PMID: 34347060 PMCID: PMC8339938 DOI: 10.1001/jamanetworkopen.2021.19212] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Multidrug-resistant organisms (MDROs) can spread across health care facilities in a region. Because of limited resources, certain interventions can be implemented in only some facilities; thus, decision-makers need to evaluate which interventions may be best to implement. OBJECTIVE To identify a group of target facilities and assess which MDRO intervention would be best to implement in the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, a large regional public health collaborative in Orange County, California. DESIGN, SETTING, AND PARTICIPANTS An agent-based model of health care facilities was developed in 2016 to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacteriaceae (CRE) for 10 years starting in 2010 and to simulate the use of various MDRO interventions for 3 years starting in 2017. All health care facilities (23 hospitals, 5 long-term acute care hospitals, and 74 nursing homes) serving adult inpatients in Orange County, California, were included, and 42 target facilities were identified via network analyses. EXPOSURES Increasing contact precaution effectiveness, increasing interfacility communication about patients' MDRO status, and performing decolonization using antiseptic bathing soap and a nasal product in a specific group of target facilities. MAIN OUTCOMES AND MEASURES MRSA and CRE prevalence and number of new carriers (ie, transmission events). RESULTS Compared with continuing infection control measures used in Orange County as of 2017, increasing contact precaution effectiveness from 40% to 64% in 42 target facilities yielded relative reductions of 0.8% (range, 0.5%-1.1%) in MRSA prevalence and 2.4% (range, 0.8%-4.6%) in CRE prevalence in health care facilities countywide after 3 years, averting 761 new MRSA transmission events (95% CI, 756-765 events) and 166 new CRE transmission events (95% CI, 158-174 events). Increasing interfacility communication of patients' MDRO status to 80% in these target facilities produced no changes in the prevalence or transmission of MRDOs. Implementing decolonization procedures (clearance probability: 39% in hospitals, 27% in long-term acute care facilities, and 3% in nursing homes) yielded a relative reduction of 23.7% (range, 23.5%-23.9%) in MRSA prevalence, averting 3515 new transmission events (95% CI, 3509-3521 events). Increasing the effectiveness of antiseptic bathing soap to 48% yielded a relative reduction of 39.9% (range, 38.5%-41.5%) in CRE prevalence, averting 1435 new transmission events (95% CI, 1427-1442 events). CONCLUSIONS AND RELEVANCE The findings of this study highlight the ways in which modeling can inform design of regional interventions and suggested that decolonization would be the best strategy for the Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County.
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Affiliation(s)
- Sarah M. Bartsch
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Kim F. Wong
- Center for Simulation and Modeling, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie E. Mueller
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Gabrielle M. Gussin
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
- Torrance Memorial Medical Center, Torrance, California
| | - Thomas Tjoa
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Patrick T. Wedlock
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
| | - Jiayi He
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Justin Chang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Shruti K. Gohil
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | | | - Susan S. Huang
- Division of Infectious Diseases and Health Policy Research Institute, Health School of Medicine, University of California–Irvine, Irvine
| | - Bruce Y. Lee
- Public Health Informatics, Computational, and Operations Research, Graduate School of Public Health and Health Policy, City University of New York, New York, New York
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Su WC, Lai YC, Lee CH, Shih CM, Chen CP, Hung LL, Wang SP. The Prevention of Periprosthetic Joint Infection in Primary Total Hip Arthroplasty Using Pre-Operative Chlorhexidine Bathing. J Clin Med 2021; 10:jcm10030434. [PMID: 33498636 PMCID: PMC7865798 DOI: 10.3390/jcm10030434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 11/26/2022] Open
Abstract
Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a devastating complication. The aim of this study was to investigate whether preoperative bathing using chlorhexidine gluconate (CHG) before THA can effectively reduce the postoperative PJI rate. A total of 933 primary THA patients, with the majority being female (54.4%) were included in the study. Primary THA patients who performed preoperative chlorhexidine bathing were assigned to the CHG group (190 subjects), and those who did not have preoperative chlorhexidine bathing were in the control group (743 subjects). The effects of chlorhexidine bathing on the prevention of PJI incidence rates were investigated. Differences in age, sex, and the operated side between the two groups were not statistically significant. Postoperative PJI occurred in four subjects, indicating an infection rate of 0.43% (4/933). All four infected subjects belonged to the control group. Although the PJI cases were significantly more in the control group than in the CHG group, statistical analysis revealed no statistical significance in the risk of PJI occurrence between the two groups (p = 0.588). Preoperative skin preparation by bathing with a 2% chlorhexidine gluconate cleanser did not produce significant effects on the prevention of postoperative PJI in primary THA.
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Affiliation(s)
- Wen-Chi Su
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
| | - Yu-Chin Lai
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Department of Food Science and Technology, HungKuang University, Taichung 43302, Taiwan
| | - Cheng-Min Shih
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Department of Physical Therapy, HungKuang University, Taichung 43302, Taiwan
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu 30010, Taiwan
| | - Chao-Ping Chen
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli County 35664, Taiwan
| | - Li-Ling Hung
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (W.-C.S.); (Y.-C.L.); (L.-L.H.)
- Department of Nursing, HungKuang University, Taichung 43302, Taiwan
| | - Shun-Ping Wang
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-H.L.); (C.-M.S.); (C.-P.C.)
- Sports Recreation and Health Management Continuing Studies-Bachelor’s Degree Completion Program, Tunghai University, Taichung 40704, Taiwan
- Correspondence:
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Routh LK, Parks NL, Gargiulo JM, Hamilton WG. Effect of a Clean Surgical Airflow Layer on the Incidence of Infection in Total Hip Arthroplasty. Orthopedics 2020; 43:e425-e430. [PMID: 32745214 DOI: 10.3928/01477447-20200721-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/22/2019] [Indexed: 02/03/2023]
Abstract
The Center for Health Design estimates that more than 30% of surgical site infections are caused by airborne pathogens. A device that creates a localized clean air field directly adjacent to and surrounding the incision site is meant to shield a surgical site from particulate in the operating room. The purpose of this study was to determine whether the routine use of this device would reduce the rate of infection following total hip arthroplasty (THA). The authors conducted a retrospective review of primary THA cases performed with and without the airflow device. Since July 2013, a total of 1093 primary THA cases were performed with the device at the authors' institution. The incidence of wound dehiscence and deep infection was compared with that of 1171 THA cases performed prior to July 2013 without the airflow device. There were no significant differences between the study groups regarding average patient age, sex, body mass index, or diagnosis. In the airflow group, there were 7 (0.64%) deep infections and 5 (0.46%) cases of wound dehiscence that required a return to the operating room for irrigation and wound revision. In the control group, there were 7 (0.60%) cases of deep infection and 4 (0.34%) wound revisions. The groups were not significantly different in the rates of infection (P=1.0) or wound revision (P=.75). Both groups had a very low incidence of infection and wound revision, with rates below 1%. Despite compelling bench data showing a dramatic reduction of particle load in the wound, the use of the airflow device did not reduce the clinical rate of infection over a large number of cases. [Orthopedics. 2020;43(5):e425-e430.].
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Berrondo C, Ahn JJ, Shnorhavorian M. Pre-operative skin antisepsis with chlorhexidine gluconate baths and wipes does not prevent postoperative surgical site infection in outpatient pediatric urologic inguinal and scrotal surgery. J Pediatr Urol 2019; 15:652.e1-652.e7. [PMID: 31564588 DOI: 10.1016/j.jpurol.2019.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION To reduce surgical site infections (SSI), many institutions utilize pre-operative antisepsis with chlorhexidine gluconate (CHG) baths and/or wipes. CHG reduces bacterial colonization of the skin, but it is unclear whether this reduces SSI, and current guidelines from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization do not support this practice. There are several factors that increase the risk of SSI in adults, but there is limited understanding of these factors in pediatric patients. OBJECTIVES The primary objectives were to describe the proportion of pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy who develop a postoperative (postop) SSI and to determine whether pre-operative CHG baths/wipes were associated with SSI. The secondary objectives were to identify other factors associated with SSI and to estimate the cost of CHG baths/wipes in this population. STUDY DESIGN Pre-operative antisepsis with CHG baths/wipes was implemented at the authors institution in 2006. The authors performed a retrospective cohort study of patients aged 0-18 years undergoing hernia/hydrocele repair and/or orchiopexy by a pediatric urologist at their institution before (2004) and after (2008) the introduction of CHG. The authors compared the proportion of patients with SSI in the no CHG and CHG groups and evaluated for factors associated with SSI. Statistical analysis included Wilcoxon rank-sum test, Chi-squared test, and Fisher's exact test. The cost of CHG baths and wipes was estimated using institutional fees in 2018 US dollars. RESULTS A total of 543 patients met inclusion criteria, 203 in the no CHG group and 340 in the CHG group. The overall rate of SSI was 0.92%. There was no association between use of CHG and SSI. No patient or peri-operative factors were associated with development of SSI. There were no CHG-associated adverse events. The cost of materials was estimated at $3.29/patient ($1118.60 for 340 cases in 2008) in 2018 US dollars. DISCUSSION SSI is not common in pediatric patients undergoing hernia/hydrocele repair or orchiopexy. In the present study, pre-operative antisepsis with CHG baths/wipes is not associated with a reduction in SSI and carries additional cost. CONCLUSIONS To the authors knowledge, this is the first study to evaluate the use of pre-operative antisepsis with CHG baths/wipes in an exclusively pediatric population. In the study, CHG baths/wipes add cost with no clear benefit for reducing SSI in pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy.
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Affiliation(s)
- Claudia Berrondo
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - Jennifer J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Abstract
Application of antiseptic products to the skin plays an important role in prevention of a variety of health care-associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care-associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted. Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.
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Atkins GJ, Alberdi MT, Beswick A, Blaha JD, Bingham J, Cashman J, Chen AF, Cooper AM, Cotacio GL, Fraguas T, Gambhir A, Gromov K, Guerra E, Hooper G, Khlopas A, Kieser D, Klaber I, Kyte R, Levine B, Mont MA, Nikolaou V, Nuñez J, Overgaard S, Parvizi J, Saxena A, Sayago G, Shahcheraghi H, Sodhi N, Solomon LB, Starczak Y, Tan TL, Tarabichi M, Olivan RT, Virolainen P, Wyatt M. General Assembly, Prevention, Surgical Site Preparation: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S85-S92. [PMID: 30348579 DOI: 10.1016/j.arth.2018.09.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Tomov M, Wanderman N, Berbari E, Currier B, Yaszemski M, Nassr A, Huddleston P, Bydon M, Freedman B. An empiric analysis of 5 counter measures against surgical site infections following spine surgery-a pragmatic approach and review of the literature. Spine J 2019; 19:267-275. [PMID: 29864545 DOI: 10.1016/j.spinee.2018.05.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/04/2018] [Accepted: 05/30/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical site infections (SSI) following spine surgery are debilitating complications to patients and costly to the healthcare system. PURPOSE Review the impact and cost effectiveness of 5 SSI prevention interventions on SSI rates in an orthopedic spine surgery practice at a major quaternary healthcare system over a 10-year period. STUDY DESIGN Retrospective observational study. PATIENT SAMPLE All of the surgical patients of the 5 spine surgeons in our department over a 10-year period were included in this study. OUTCOME MEASURES SSI rates per year, standardized infection ratios (SIR) for laminectomies and fusions during the most recent 3-year period, year of implementation, and frequency of use of the different interventions, cost of the techniques. METHODS The SSI prevention techniques described in this paper include application of intrawound vancomycin powder, wound irrigation with dilute betadine solution, preoperative chlorhexidine gluconate scrubs, preoperative screening with nasal swabbing, and decolonization of S. aureus, and perioperative antibiotic administration. Our institution's infection prevention and control data were analyzed for the yearly SSI rates for the orthopedic spine surgery department from 2006 to 2016. In addition, our orthopedic spine surgeons were polled to determine with what frequency and duration they have been using the different SSI prevention interventions. RESULTS SSI rates decreased from almost 6% per year the first year of observation to less than 2% per year in the final 6 years of this study. A SIR of less than 1.0 for each year was observed for laminectomies and fusions for the period from 2013 to 2016. All surgeons polled at our institution uniformly used perioperative antibiotics, Hibiclens scrub, and the nasal swab protocol since the implementation of these techniques. Some variability existed in the frequency and duration of betadine irrigation and application of vancomycin powder. A cost analysis demonstrated these methods to be nominal compared with the cost of treating a single SSI. CONCLUSIONS It is possible to reduce SSI rates in spine surgery with easy, safe, and cost-effective protocols, when implemented in a standardized manner.
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Affiliation(s)
- Marko Tomov
- Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | | | - Elie Berbari
- Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | | | | | - Ahmad Nassr
- Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | | | - Mohamad Bydon
- Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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Carlson BC, Milbrandt TA, Larson AN. Quality, Safety, and Value in Pediatric Spine Surgery. Orthop Clin North Am 2018; 49:491-501. [PMID: 30224010 DOI: 10.1016/j.ocl.2018.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The article addresses patient safety topics in spine surgery, including infection, length of stay, instrumentation strategies, pedicle screw malposition, radiation exposure, and neurologic events. Quality, safety, and value are concepts that are practical, easy to understand, and can be implemented on any scale and may be matched to individual practices. Further, with quality improvement, there is a culture shift to openly share information, protocols, and strategies so that more patients can rapidly benefit.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Todd A Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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DeRogatis MJ, Mahon AM, Lee P, Issack PS. Perioperative Considerations to Reduce Infection Risk in Primary Total Hip and Knee Arthroplasty. JBJS Rev 2018; 6:e8. [PMID: 29664871 DOI: 10.2106/jbjs.rvw.17.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
This article reviews the literature that supports routine expectations for smoking cessation; weight loss; diabetic, nutritional, or metabolic optimization; and decolonization techniques before ventral hernia repair. These methods diminish postoperative complications. In an era of value-centric care, an upfront investment in patient optimization can improve the quality of the repair by reducing wound morbidity and hernia recurrence, naturally translating to a reduction in cost. The adoption of these practices and further study aimed at identifying other effective optimization techniques are encouraged.
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Affiliation(s)
- Clayton C Petro
- Department of Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Ajita S Prabhu
- Department of Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Wang Z, Zheng J, Zhao Y, Xiang Y, Chen X, Zhao F, Jin Y. Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty: A meta-analysis. Medicine (Baltimore) 2017; 96:e8321. [PMID: 29381914 PMCID: PMC5708913 DOI: 10.1097/md.0000000000008321] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Surgical site infection is a devastating postoperative complication, and the occurrence ranges from 1% to 2% after total knee arthroplasty (TKA). The efficacy of the preoperative use of chlorhexidine for reducing infection has been debated. This meta-analysis aimed to examine the efficacy of the use of chlorhexidine to prevent surgical site infections after TKA. METHODS In February 2017, a systematic literature review was conducted using the following electronic databases: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and the Google database. Data from randomized controlled trials (RCTs) and retrospective comparative study (RCS) that compared the use of chlorhexidine versus control washes to prep patients for TKA were retrieved. The primary endpoint was to compare the total incidence of infection with and without the use of chlorhexidine. The secondary outcomes were the incidence of infection in low-risk category patients, moderate-risk category patients, and high-risk category patients. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects modeling when necessary. RESULTS Four clinical trials that included 8787 patients (chlorhexidine group: n = 2615, control group: n = 6172) were ultimately included in the meta-analysis. Chlorhexidine was associated with a reduced total incidence of infection, corresponding to a reduction of 1.69% [risk ratio (RR) = 0.22; 95% confidence interval (95% CI) = 0.12-0.40; P = .000]. Similarly, chlorhexidine was associated with a reduction in the incidence of infection among patients in the moderate-risk category (RR, 0.18; 95% CI, 0.05-0.63; P = .007) and the high-risk category (RR, 0.13; 95% CI, 0.03-0.67; P = .014). There was no significant difference between the incidence of infection in low-risk category patients with chlorhexidine use compared with the use of control washes (RR, 0.60; 95% CI, 0.22-1.60; P = .330). CONCLUSION The preoperative use of chlorhexidine could reduce the total incidence of infection and the incidence of infection in moderate-risk and high-risk category patients. The overall evidence and the number of included studies was limited; thus, a greater number of high-quality RCTs is still needed to further identify the effects of chlorhexidine on reducing the incidence of infection after TKA.
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Affiliation(s)
- Zhen Wang
- Department of Orthopaedics, Henan Provincial People's Hospital
| | - Jia Zheng
- Department of Orthopaedics, Henan Provincial People's Hospital
| | - Yongqiang Zhao
- Department of Orthopaedics, Henan Provincial People's Hospital
| | - Yungai Xiang
- Department of Reproductive Center, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xiao Chen
- Department of Orthopaedics, Henan Provincial People's Hospital
| | - Fei Zhao
- Department of Orthopaedics, Henan Provincial People's Hospital
| | - Yi Jin
- Department of Orthopaedics, Henan Provincial People's Hospital
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Chen AF, Nana AD, Nelson SB, McLaren A. What's New in Musculoskeletal Infection: Update Across Orthopaedic Subspecialties. J Bone Joint Surg Am 2017; 99:1232-1243. [PMID: 28719563 DOI: 10.2106/jbjs.17.00421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Antonia F Chen
- 1Rothman Institute, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 2John Peter Smith Hospital, Fort Worth, Texas 3Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 4University of Arizona, College of Medicine-Phoenix, Phoenix, Arizona
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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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Lee C, Pizarro-Berdichevsky J, Clifton MM, Vasavada SP. Sacral Neuromodulation Implant Infection: Risk Factors and Prevention. Curr Urol Rep 2017; 18:16. [PMID: 28224396 DOI: 10.1007/s11934-017-0663-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Device infection is one of the most common complications of sacral nerve stimulator placement and occurs in approximately 3-10% of cases. Infection is a serious complication, as it often requires complete explantation of the device. Not much is known regarding risk factors for and methods of preventing infection in sacral nerve stimulation. Multiple risk factors have been linked to device infection including prolonged percutaneous testing and choice of preoperative antibiotic. Methods of infection prevention have also been studied recently, including antibiotic-impregnated collage and type of skin preparation. This review will discuss the recent literature identifying risk factors and means of preventing infection in sacral nerve stimulation. Finally, we will outline a protocol we have enacted at our institution which has resulted in an incidence of infection of 1.6%.
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Affiliation(s)
- Calvin Lee
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Javier Pizarro-Berdichevsky
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
- Urogynecology Unit, Hospital Dr. Sotero del Rio, Santiago, Chile
- Division de Obstetricia y Ginecologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marisa M Clifton
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Sandip P Vasavada
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
- Department of Urology, Cleveland Clinic Foundation, Q10-1, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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26
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Cai Y, Xu K, Hou W, Yang Z, Xu P. Preoperative chlorhexidine reduces the incidence of surgical site infections in total knee and hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2017; 39:221-228. [PMID: 28189811 DOI: 10.1016/j.ijsu.2017.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/14/2017] [Accepted: 02/05/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This meta-analysis aims to assess the incidences of surgical site infection of patients who applied preadmission chlorhexidine skin preparation, versus those who applied the traditional skin preparation before undergoing total knee and hip arthroplasty. METHODS A systematic search is carried out through Medline (1966-2016.11), PubMed (1966-2016.11), Embase (1980-2016.11), ScienceDirect (1985-2016.11) and the Cochrane Library. Only high quality studies are identified. Meta-analysis is conducted with the use of Stata 11.0 software. RESULTS One RCT and five retrospective studies, published between 2010 and 2016, are included in the present meta-analysis. The present meta-analysis indicates that there are significant differences in surgical site infection rate (RD = -0.02, 95% CI: -0.02 to -0.01, P < 0.00001), revision surgery rate (RD = -0.01, 95% CI: -0.01 to -0.01, P < 0.00001) and length of stay (MD = -0.29, 95% CI: -0.48 to -0.11, P = 0.002) between groups. CONCLUSION Preoperative chlorhexidine skin preparation appears to reduce the risk of infection, the incidence of revision surgery, and the length of stay for patients undergoing total knee and hip arthroplasty. No adverse effects, such as DVT or PE, appear to be related to chlorhexidine preparation. Due to the limited quality of the evidence currently available, high quality RCTs with better study designs, larger sample sizes and longer follow-ups are needed.
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Affiliation(s)
- Yuanzhen Cai
- Department of Joint Surgery Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xian, 710054, China
| | - Ke Xu
- Department of Joint Surgery Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xian, 710054, China
| | - Weikun Hou
- Department of Joint Surgery Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xian, 710054, China
| | - Zhi Yang
- Department of Joint Surgery Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xian, 710054, China
| | - Peng Xu
- Department of Joint Surgery Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xian, 710054, China.
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27
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Abstract
Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). Chlorhexidine is a widely used antiseptic because of its rapid and persistent action. It is well tolerated and available in different formulations at various concentrations. Chlorhexidine can be used for pre-operative skin cleansing, surgical site preparation, hand antisepsis of the surgical team and intra-articular irrigation of infected joints. The optimal intra-articular concentration of chlorhexidine gluconate in irrigation solution is 2%, to provide a persistent decrease in biofilm formation, though cytotoxicity might be an issue. Although chlorhexidine is relatively cheap, routine use of chlorhexidine without evidence of clear benefits can lead to unnecessary costs, adverse effects and even emergence of resistance. This review focuses on the current applications of various chlorhexidine formulations in TJA. As the treatment of PJI is challenging and expensive, effective preparations of chlorhexidine could help in the prevention and control of PJI.
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Affiliation(s)
- Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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28
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Prabhu AS, Krpata DM, Phillips S, Huang LC, Haskins IN, Rosenblatt S, Poulose BK, Rosen MJ. Preoperative Chlorhexidine Gluconate Use Can Increase Risk for Surgical Site Infections after Ventral Hernia Repair. J Am Coll Surg 2016; 224:334-340. [PMID: 28017808 DOI: 10.1016/j.jamcollsurg.2016.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 12/07/2016] [Accepted: 12/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is varying evidence about the use of preoperative chlorhexidine gluconate to decrease surgical site infection for elective surgery. This intervention has never been studied in ventral hernia repair, the most common general surgery procedure in the US. We aimed to determine whether preoperative chlorhexidine gluconate decreases the risk of 30-day wound morbidity in patients undergoing ventral hernia repair. STUDY DESIGN All patients undergoing ventral hernia repair in the Americas Hernia Society Quality Collaborative were separated into 2 groups: 1 group received preoperative chlorhexidine scrub and the other did not. The 2 groups were evaluated for 30-day wound morbidity, including surgical site occurrence (SSO), surgical site infection (SSI), and SSO requiring procedural intervention. Statistical analysis was performed using multivariate regression analysis and propensity score modeling. Multiple factors were controlled for statistical analysis, including patient-related factors and operative factors. RESULTS In total, 3,924 patients were included for comparison. After multivariate logistic regression modeling, the preoperative chlorhexidine scrub group had a higher incidence of SSOs (odds ratio [OR] = 1.34; 95% CI 1.11 to 1.61) and SSIs (OR = 1.46; 95% CI 1.03 to 2.07). After propensity score modeling, the increased risk of SSO and SSI persisted (SSO: OR = 1.39; 95% CI 1.15 to 1.70; SSI: OR = 1.45; 95% CI 1.011 to 2.072, respectively). CONCLUSIONS Prehospital chlorhexidine gluconate scrub appears to increase the risk of 30-day wound morbidity in patients undergoing ventral hernia repair. These findings suggest that the generalized use of prehospital chlorhexidine might not be desirable for all surgical populations.
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Affiliation(s)
- Ajita S Prabhu
- Comprehensive Hernia Center, Digestive Disease and Surgical Institute, The Cleveland Clinic Foundation, Cleveland, OH.
| | - David M Krpata
- Comprehensive Hernia Center, Digestive Disease and Surgical Institute, The Cleveland Clinic Foundation, Cleveland, OH
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Li-Ching Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Ivy N Haskins
- Comprehensive Hernia Center, Digestive Disease and Surgical Institute, The Cleveland Clinic Foundation, Cleveland, OH
| | - Steven Rosenblatt
- Comprehensive Hernia Center, Digestive Disease and Surgical Institute, The Cleveland Clinic Foundation, Cleveland, OH
| | - Benjamin K Poulose
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Michael J Rosen
- Comprehensive Hernia Center, Digestive Disease and Surgical Institute, The Cleveland Clinic Foundation, Cleveland, OH
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