Efficacy of preoperative screening and decolonization for staphylococcus aureus in total joint arthroplasty: A meta-analysis

Spine surgical site infection outcome with preoperative application of a presaturated 10% povidone-iodine nasal decolonization product in a 32-bed surgical hospital

BACKGROUND

To pursue an irreducible minimum overall surgical site infection (SSI) rate, a 32-bed surgical hospital employed an outside consultant and performed sterile processing and surgery internal audits: No obvious improvements were identified. A 10-year review determined that 70% of SSI's were spine procedure patients. After a nasal decolonization product literature review, an intervention was implemented. The purpose of this study was to assess if the intervention impacted spine SSI rates.

METHODS

A 36-month implementation science study was conducted. The 18-month intervention was the immediate preoperative application of a manufactured presaturated 10% povidone-iodine nasal decolonization product in spine surgery patients, with monthly product application documentation surveillance feedback to the preoperative staff. Chi-square test was used to determine the difference in types of spine SSI surgery rates pre and post intervention.

RESULTS

Overall spine SSI decreased 35.7% (P = .04) with a 58.7% reduction in superficial incisional SSI (P = .02). The 16.1% decline in deep incisional SSI was not significant (P = .29).

CONCLUSIONS

Within this hospital, conducting 7,576 surgical spine procedures over 36 months, with the immediate preoperative application of a presaturated 10% povidone-iodine nasal decolonization product, the only intervention in SSI prevention protocol, produced a statistically significant decrease in spine patient SSI rate percent.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Diagnostic Values of Serum Inflammatory Biomarkers after Hip and Knee Arthroplasty in Patients with Periprosthetic Joint Infection

One of the complications after total hip arthroplasty (THA) or total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). Numerous studies have been performed to explore the value of biological parameters in the early identification of infection rates after THA and TKA. This study investigates alterations in inflammatory markers associated with PJI. This retrospective study focused on a cohort of patients with hip and knee arthroplasty treated between 2016 and 2022. CRP, ESR, and fibrinogen were observed preoperatively, on days one, three, six, and twenty-one postoperatively. From a total of 4076 THA and TKA performed during this period, 62 patients were identified with periprosthetic infections. We also identified the pathogens responsible for infections in order to assess if asymptomatic preoperative infections were involved in PJI. In patients with acute infections following TKA, days one and three postoperative recorded a CRP value below the expected range. The value of CRP in patients with early infection after THA was significantly increased on day six postoperative. ESR and fibrinogen values were not statistically significantly correlated with early PJI. The CRP level in acute PJI shows different patterns than those shown in the literature.

Cost-effectiveness and clinical utility of universal pre-admission MRSA screening in total joint arthroplasty patients

BACKGROUND

For patients undergoing total joint arthroplasty (TJA), pre-admission meticillin-resistant Staphylococcus aureus (MRSA) nasal screening has been widely adopted to prevent postoperative joint infection. However, screening cost-effectiveness and clinical utility have not been adequately evaluated.

AIM

To assess the MRSA infection rate, associated costs, and costs of screening at our institution, before and after screening implementation.

METHODS

This was a retrospective cohort study examining patients who underwent TJA at a health system in New York State, between 2005 and 2016. Patients were divided into the 'no-screening' group if the operation occurred prior to adoption of the MRSA screening protocol in 2011 and the 'screening' group if afterwards. The number of MRSA joint infections, cost of each infection, and costs associated with preoperative screening were recorded. Fisher's exact test and cost comparison analysis were performed.

FINDINGS

The no-screening group had four MRSA infections in 6088 patients over a seven-year period, whereas the screening group had two in 5177 patients over five years. Fisher's exact test showed no significant association between screening and MRSA infection rate (P = 0.694). The cost of postoperative MRSA joint infection treatment was US$40,919.13 per patient, whereas annual nasal screening was US$103,999.97.

CONCLUSION

At our institution, MRSA screening had little impact on infection rates and led to increased costs, with 2.5 MRSA infections required annually to meet the costs of screening. Therefore, the screening protocol may be best suited for high-risk populations, rather than the average TJA patient. The authors recommend a similar clinical utility and cost-effectiveness analysis at other institutions implementing MRSA screening programmes.

[Translated article] Results of a preoperative screening and decolonization programme for Staphylococcus aureus in primary hip and knee arthroplasty

INTRODUCTION

Detection and decolonization of Staphylococcus aureus prior to surgery is postulated as an option to reduce the risk of infection in arthroplasties. The aim of this study was to evaluate the effectiveness of a screening programme for S. aureus in total knee arthroplasty (TKA) and total hip arthroplasty (THA), the incidence of infection with respect to a historical cohort, and its economic viability.

MATERIAL AND METHODS

Pre-post intervention study in patients undergoing primary knee and hip prostheses in 2021, a protocol was carried out to detect nasal colonization by S. aureus and eradication if appropriate, with intranasal mupirocin, post-treatment culture with results three weeks between post-treatment culture and surgery. Efficacy measures are evaluated, costs are analyzed and the incidence of infection is compared with respect to a historical series of patients operated on between January and December 2019, performing a descriptive and comparative statistical analysis.

RESULTS

The groups were statistically comparable. Culture was performed in 89%, with 19 (13%) positive patients. Treatment was confirmed in 18, control culture in 14, all decolonized; none suffered infection. One culture-negative patient suffered from Staphylococcus epidermidis infection. In historical cohort: three suffered deep infection by S. epidermidis, Enterobacter cloacae, Staphylococcus aureus. The cost of the programme is €1661.85.

CONCLUSION

The screening programme detected 89% of the patients. The prevalence of infection in the intervention group was lower than in the cohort, with S. epidermidis being the main micro-organism, different from S. aureus described in the literature and in the cohort. We believe that this programme is economically viable, as its costs are low and affordable.