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Rice S, Carr K, Sobiesuo P, Shabaninejad H, Orozco-Leal G, Kontogiannis V, Marshall C, Pearson F, Moradi N, O'Connor N, Stoniute A, Richmond C, Craig D, Allegranzi B, Cassini A. Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review. THE LANCET. INFECTIOUS DISEASES 2023; 23:e228-e239. [PMID: 37001543 DOI: 10.1016/s1473-3099(22)00877-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 03/30/2023]
Abstract
Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.
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Affiliation(s)
- Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Katherine Carr
- Dental School, Newcastle University, Newcastle upon Tyne, UK
| | - Pauline Sobiesuo
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Giovany Orozco-Leal
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Christopher Marshall
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Pearson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Najmeh Moradi
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicole O'Connor
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Akvile Stoniute
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Richmond
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Benedetta Allegranzi
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
| | - Alessandro Cassini
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, WHO, Geneva, Switzerland
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Wilson E, Marra AR, Ward M, Chapin L, Boulden S, Ryken TC, Jones LC, Herwaldt LA. Patients' experiences and compliance with preoperative screening and decolonization. Am J Infect Control 2023; 51:78-82. [PMID: 35339622 DOI: 10.1016/j.ajic.2022.03.013] [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: 12/06/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND To improve adherence with pre-surgical screening for Staphylococcus aureus nasal carriage and decolonization, we need more information about patients' experiences with these protocols. METHODS We surveyed patients undergoing orthopedic, neurosurgical, or cardiac operations at Johns Hopkins Hospitals (JHH), the University of Iowa Hospitals and Clinics (UIHC) at MercyOne Northeast Iowa Neurosurgery (MONIN) to assess patients' experiences with decolonization protocols. RESULTS Five hundred thirty-four patients responded. Respondents at JHH were significantly more likely than those at the UIHC to report using mupirocin and were significantly more likely than those at the UIHC and MONIN to feel they received adequate information about surgical site infection (SSI) prevention and decolonization. Respondents at JHH were the least likely to not worry about SSI and they were more willing to do anything they could to prevent SSI. Few patients reported barriers to adherence and side effects of mupirocin or chlorhexidine. CONCLUSION Respondents did not report either major side effects or barriers to adherence. Patients varied in their level of concern about SSI, their willingness to invest effort in preventing SSI, and their assessments of preoperative information. To improve patients' adherence, clinicians and hospitals should assess their patients' needs and desires and tailor their preoperative processes, education, and prophylaxis accordingly.
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Affiliation(s)
- Ethan Wilson
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA
| | - Alexandre R Marra
- University of Iowa Hospitals & Clinics, Iowa City, IA, USA; Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Melissa Ward
- University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA
| | - Laura Chapin
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA
| | | | - Timothy C Ryken
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA; Dartmouth-Hitchcock Medical Center, Department of Neurosurgery, Lebanon, NH, USA
| | - Lynne C Jones
- Johns Hopkins School of Medicine, Department of Orthopaedic Surgery, Baltimore, MD, USA
| | - Loreen A Herwaldt
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA.
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Luck T, Zaki P, Michels R, Slotkin EM. The Cost-Effectiveness of Normal-Saline Pulsed Lavage for Infection Prophylaxis in Total Joint Arthroplasty. Arthroplast Today 2022; 18:107-111. [PMID: 36304695 PMCID: PMC9593269 DOI: 10.1016/j.artd.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Prosthetic joint infection (PJI) is a well-described complication after total joint arthroplasty which imposes a substantial burden of morbidity and mortality on the individual, as well as cost to the health-care system. This study used a break-even analysis to investigate the cost-effectiveness of pulsed saline lavage (PSL) for PJI prophylaxis after a primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods An established model was used to calculate the minimum cost-effective absolute risk reduction of PSL for infection prophylaxis after a total joint arthroplasty. Baseline infection rates of TKA and THA and the cost of a revision surgery for PJI were derived from the literature while the cost of PSL implementation was obtained from institutional data. Results PSL is cost-effective at an initial infection rate of 1.10%, revision costs of $32,132 for TKA PJI, and a protocol cost of $38.28 if it reduces infection rates by 0.12% or prevents infection in 1 out of 839 patients. PSL is cost-effective at an initial infection rate of 1.63% and a revision cost of $39,713 for THA PJI if it reduces infection rates by 0.10% or prevents infection in 1 out of 1037 patients. The absolute risk reduction needed for economic viability did not change with varying baseline infection rates and did not exceed 0.38% for infection treatment costs as low as $10,000 and remained less than 0.47% even if PSL cost was as high as $150. Conclusions The use of PSL is a cost-effective protocol for PJI prophylaxis after TKAs and THAs.
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Affiliation(s)
- Trevor Luck
- Drexel University College of Medicine, Philadelphia, Pennsylvania,Corresponding author. Drexel University College of Medicine, 613 Sandstone Drive, Wyomissing, PA 19610, USA. Tel.: +1 207 590 8513.
| | - Peter Zaki
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ryan Michels
- Reading Hospital, Orthopaedic Associates of Reading, Wyomissing, Pennsylvania
| | - Eric M. Slotkin
- Reading Hospital, Orthopaedic Associates of Reading, Wyomissing, Pennsylvania
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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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Rucinski K, Stannard JP, Leary EV, Cook JL. Incidence and Cost of Surgical Site Infections After Osteochondral Allograft Transplantation and Meniscal Allograft Transplantation in the Knee. Orthop J Sports Med 2022; 10:23259671221084701. [PMID: 35299714 PMCID: PMC8921752 DOI: 10.1177/23259671221084701] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Surgical site infections (SSIs) significantly influence outcomes and health care costs after orthopaedic surgery, but they have not been well characterized for osteochondral allograft (OCA) transplantation with or without meniscal allograft transplantation (MAT). Purpose: To characterize the incidence, cost, and risk factors associated with potential or confirmed SSIs after large single-surface, multisurface, or bipolar allograft transplantation in the knee. Study Design: Case-control study; Level of evidence, 3. Methods: Prospectively collected registry data were analyzed for patients who underwent primary or revision OCA transplantation with or without MAT in the knee. The Centers for Disease Control and Prevention (CDC) guidelines were used to define SSIs and calculate the SSI incidence. Both potential and confirmed SSIs were analyzed to determine related treatment methods, calculate associated health care costs, and characterize risk factors based on the OCA surgery type (single-surface, multisurface, bipolar, ±MAT), American Society of Anesthesiologists physical status classification system, surgery duration, length of stay, age, sex, body mass index (BMI), and current tobacco use. Results: A total of 224 patients were included in the analysis. There were 2 SSIs in 1 patient that met CDC criteria, such that the incidence for this patient population was 0.9%. An additional 7 patients (3.1%) were examined for potential infections not classified as SSIs. Patients with potential or confirmed SSIs had a significantly higher mean BMI compared to patients with no evidence of an SSI ( P <.001). BMI >35 (odds ratio, 9.1) and tobacco use (odds ratio, 6.6) were associated with greater odds for a potential or confirmed SSI. The mean health care costs were $6101 for patients who required additional emergency room visits and/or irrigation and debridement within 90 days postoperatively for potential or confirmed SSIs, $19 for patients with potential superficial incisional SSIs, and $12,100 for patients who experienced a potential or confirmed deep incisional or organ/space SSI >90 days from surgery. Conclusion: Large OCA transplantation with and without MAT were associated with a low incidence of confirmed SSIs (0.9%), and patients with BMI >35 and current tobacco use had greater odds of an SSI. Potential and confirmed SSIs were associated with unscheduled appointments, additional surgical procedures, and higher costs.
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Affiliation(s)
- Kylee Rucinski
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - James P. Stannard
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Emily V. Leary
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - James L. Cook
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
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Kampmeier T, Rehberg S, Omar Alsaleh AJ, Schraag S, Pham J, Westphal M. Cost-Effectiveness of Propofol (Diprivan) Versus Inhalational Anesthetics to Maintain General Anesthesia in Noncardiac Surgery in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:939-947. [PMID: 34243837 DOI: 10.1016/j.jval.2021.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/17/2020] [Accepted: 01/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES It is not known whether using propofol total intravenous anaesthesia (TIVA) to reduce incidence of postoperative nausea and vomiting (PONV) is cost-effective. We assessed the economic impact of propofol TIVA versus inhalational anesthesia in adult patients for ambulatory and inpatient procedures relevant to the US healthcare system. METHODS Two models simulate individual patient pathways through inpatient and ambulatory surgery with propofol TIVA or inhalational anesthesia with economic inputs from studies on adult surgical US patients. Efficacy inputs were obtained from a meta-analysis of randomized controlled trials. Probabilistic and deterministic sensitivity analyses assessed the robustness of the model estimates. RESULTS Lower PONV rate, shorter stay in the post-anesthesia care unit, and reduced need for rescue antiemetics offset the higher costs for anesthetics, analgesics, and muscle relaxants with propofol TIVA and reduced cost by 11.41 ± 10.73 USD per patient in the inpatient model and 11.25 ± 9.81 USD in the ambulatory patient model. Sensitivity analyses demonstrated strong robustness of the results. CONCLUSIONS Maintenance of general anesthesia with propofol was cost-saving compared to inhalational anesthesia in both inpatient and ambulatory surgical settings in the United States. These economic results support current guideline recommendations, which endorse propofol TIVA to reduce PONV risk and enhance postoperative recovery.
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Affiliation(s)
- Tim Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany.
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, University Hospital OWL, Campus Bielefeld-Bethel, Bielefeld, Germany
| | | | - Stefan Schraag
- Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, Scotland, UK
| | - Jenny Pham
- Medical, Clinical, and Regulatory Affairs, Fresenius Kabi AG, Bad Homburg, Germany
| | - Martin Westphal
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Muenster, Muenster, Germany and Fresenius Kabi AG, Bad Homburg, Germany
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Morsi SS, Omar A, Hebbar G, Al-Fadhli M, Hamza WS. Effect of multidimensional intervention to reduce surgical site infection rate after knee and hip arthroplasty. Germs 2021; 11:10-22. [PMID: 33898337 DOI: 10.18683/germs.2021.1236] [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: 07/20/2020] [Revised: 11/17/2020] [Accepted: 12/30/2020] [Indexed: 11/08/2022]
Abstract
Introduction Prevention strategies are critical to reduce infection rates in joint arthroplasty. This study aimed to investigate the effectiveness of a set of evidence-based practices to reduce surgical site infection (SSI) rates after knee and hip arthroplasty (HPRO & KPRO). Methods A quasi-experimental study design (comparing pre- and post-intervention phases) was applied. Interventions were selected, adapted, and implemented in knee and hip arthroplasty procedures as a prospective practice. They consisted of 13 processes throughout the surgical encounter, including preoperative, intraoperative, and postoperative elements. Results Regarding hip arthroplasty procedures, the overall SSI rate during the pre-intervention period was 11.9%, which was reduced significantly to 5.1% (57% reduction) in the intervention period (p=0.042). For knee arthroplasty procedures, the overall baseline SSI rate during the pre-intervention period was 2.7%, which was reduced to 2.0% (26% reduction) in the intervention period. However, this reduction was not statistically significant (p=0.561). Combined methicillin-resistant Staphylococcus aureus (MRSA) screening with appropriate decolonization and targeted prophylaxis were associated with a 50% reduction in SSI caused by MRSA in knee arthroplasty. Conclusions The implementation of multidimensional evidence-based practices was associated with a reduction in SSI following knee and hip arthroplasties.
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Affiliation(s)
- Samar Saeed Morsi
- PhD, Associate Professor at Department of Microbiology and Immunology, Faculty of Medicine, Zagazig University, Egypt, Consultant of Infection Control, Al-Razi Orthopedic Hospital, Kuwait, Sabah health region, P.O. Box: 12414 Alshamiya, Kuwait
| | - Abeer Omar
- PhD, Head of Surveillance Department, at Infection Control Directorate, Ministry of Health, Sabah health region, P.O. Box: 12414 Alshamiya, Kuwait
| | - Gautam Hebbar
- MPH, Epidemiologist at Infection Control Directorate, Ministry of Health, Sabah health region, P.O. Box: 12414 Alshamiya, Kuwait
| | - Mariam Al-Fadhli
- PhD, Former Director of Infection Control Directorate, Ministry of Health, Sabah health region, P.O. Box: 12414 Alshamiya, Kuwait
| | - Wafaa S Hamza
- PhD, Associate Professor at Department of Public Health and Community Medicine, Faculty of Medicine, Assiut University, Egypt, Consultant of Infection Control at Infection Control Directorate, Ministry of Health, Kuwait, Sabah health region, P.O. Box: 12414 Alshamiya
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What is the most cost-effective strategy for nasal screening and Staphylococcus aureus decolonization in patients undergoing total hip arthroplasty? BMC Musculoskelet Disord 2021; 22:129. [PMID: 33522920 PMCID: PMC7849129 DOI: 10.1186/s12891-021-04008-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
Background To reduce periprosthetic joint infection after total hip arthroplasty (THA), several nasal screening and decolonization strategies for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) have been performed. These include universal decolonization (UD; i.e., no screening and decolonization for all patients), universal screening and target decolonization (US; i.e., screening for all patients and decolonization for bacterial positive patients), and target screening and decolonization (TS; i.e., screening and decolonization for high-risk populations only). Although TS is the most cost-effective strategy, useful risk factors must be identified. The purpose of this study was to evaluate the presence of predictive factors that enable the TS strategy to be successfully implemented and to compare the costs of each strategy. Methods A total of 1654 patients scheduled for primary or revision THA (1464 female, 190 male; mean age 64 years) were screened prior to surgery for bacterial colonization of the nasal mucosa. Risk factors for positive MRSA and S. aureus (including both MRSA and MSSA) tests were analyzed according to the following parameters: sex, age ≥ 80 years, body mass index ≥ 30 kg/m2, antibiotic use within 3 years, corticosteroid use, serum albumin < 3.5 g/dL, glomerular filtration rate < 50 mL/min, presence of brain, thyroid, cardiac, or pulmonary disease, diabetes, asthma, smoking status, and whether revision surgery was performed. The average cost of each strategy was calculated. Results In total, 29 patients (1.8 %) tested positive for MRSA and 445 (26.9 %) tested positive for S. aureus. No parameters were identified as independent risk factors for MRSA and only female sex was identified as a risk factor for S. aureus (p = 0.003; odds ratio: 1.790; 95 % confidence interval: 1.210–2.640). The average cost of each strategy was 1928.3 yen for UD, 717.6 yen for US, and 717.6 yen for TS (for eradicating MRSA), and 1928.3 yen for UD, 1201.6 yen for US, and 1160.4 yen for TS (for eradicating S. aureus). Conclusions No useful predictive parameters for implementing the TS strategy were identified. Based on cost implications, US is the most cost-effective strategy for THA patients.
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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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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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Does Preoperative Decolonization Reduce Surgical Site Infections in Elective Orthopaedic Surgery? A Prospective Randomized Controlled Trial. Clin Orthop Relat Res 2020; 478:1790-1800. [PMID: 32058435 PMCID: PMC7371089 DOI: 10.1097/corr.0000000000001152] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) after elective orthopaedic surgery are very stressful for patients due to frequent rehospitalizations with reoperations and poorer functional outcomes. Prevention of such events is therefore crucial. Although an evidence-based consensus is still lacking, preoperative decolonization could decrease SSI. Specifically, more information is needed about the effect of a preoperative decolonization procedure on SSI proportions in both Staphylococcus aureus carriers and non-S. aureus carriers after general orthopaedic surgery. QUESTIONS/PURPOSES Our study addressed the following questions: (1) Does preoperative decolonization reduce the risk of SSI after general elective orthopaedic surgery in patients colonized with S. aureus? (2) Does preoperative decolonization reduce the risk of SSI among patients who are not colonized with S. aureus? METHODS In this prospective, randomized, single-blinded trial, we recruited patients undergoing general elective orthopaedic surgery in one tertiary care center in Switzerland. Between November 2014 and September 2017, 1318 of 1897 screened patients were enrolled. Patients were allocated into either the S. aureus carrier group (35%, 465 of 1318 patients) or the noncarrier group (65%, 853 of 1318 patients) according to screening culture results. In the S. aureus group, 232 patients were allocated to the intervention arm and 233 were allocated to the control arm. Intervention was 5 days of daily chlorhexidine showers and mupirocin nasal ointment twice a day. Of the 853 noncarriers, 426 were allocated to the intervention arm and 427 were allocated to the control arm. All patients in both groups were analyzed in an intention-to-treat manner. The primary endpoint was SSI occurrence at 90 days postoperative and the secondary endpoint was SSI occurrence at 30 days postoperative.The initial sample size calculation was made for the S. aureus carrier group. Based on the literature review, a 4% proportion of SSI was expected in the control group. Thus, 726 carriers would have been needed to detect a relative risk reduction of 80% with a power of 80% at a two-sided α-error of 0.048 (adjusted for interim analysis). Assuming carrier prevalence of 27%, 2690 patients would have been needed in total. An interim analysis was performed after including half of the targeted S. aureus carriers (363 of 726). Based on the low infection rate in the control group (one of 179), a new sample size of 15,000 patients would have been needed. This was deemed not feasible and the trial was stopped prematurely. RESULTS Among carriers, there was no difference in the risk of SSI between the intervention and control arms (decolonized SSI risk: 0.4% [one of 232], control SSI risk: 0.4% [one of 233], risk difference: 0.0% [95% CI -1.2% to 1.2%], stratified for randomization stratification factors; p > 0.999). For noncarriers, there was no difference in risk between the intervention and control arms (decolonized SSI risk: 0.2% [one of 426], control SSI risk: 0.2% [one of 247], stratified risk difference: -0.0% [95% CI -0.7 to 0.6]; p = 0.973). CONCLUSIONS We found no difference in the risk of SSI between the decolonization and control groups, both in S. aureus carriers and noncarriers. Because of the low event numbers, no definite conclusion about efficacy of routine preoperative decolonization can be drawn. The results, however, may be helpful in future meta-analyses. LEVEL OF EVIDENCE Level II, therapeutic study.
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12
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Cost-Effectiveness of Arthroplasty Management in Hip and Knee Osteoarthritis: a Quality Review of the Literature. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Schweitzer D, Klaber I, García P, López F, Lira MJ, Botello E. Methicillin-resistant Staphylococcus aureus colonization in patients undergoing primary total hip arthroplasty. J Med Microbiol 2020; 69:600-604. [PMID: 32427561 DOI: 10.1099/jmm.0.001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Nasal and skin colonization by methicillin-resistant Staphylococcus aureus (MRSA) are linked to a higher incidence of infection after total joint replacement. The prevalence of colonization is poorly defined in Latin American countries.Aim. The aim of the present study was to determine the prevalence of MRSA colonization in the nostrils and groin using real-time polymerase chain reaction (RT-PCR) in patients undergoing total hip arthroplasty (THA).Methodology. In this cross-sectional study, 146 patients undergoing THA between December 2015 and March 2017 in a tertiary-care university-affiliated hospital in Chile were screened for MRSA colonization before the procedure using RT-PCR independently in the nostrils and groin. Risk factors for colonization were documented.Results. Seven of the 146 (5 %) patients undergoing THA were carriers of MRSA in the nostrils and/or the groin. Recent antibiotic use was identified as a risk factor for colonization, OR=4.86 [95 % confidence interval (CI): 1.56-13.96]. Patients reporting at least one of the seven surveyed risk factors had an OR of 2.39 (95 % CI: 0.37-25.77) for colonization. MRSA colonization frequency was twofold higher in the groin as opposed to the nostrils (P=0.014).Conclusion. Five percent of the patients undergoing THA were identified as carriers of MRSA. Recent antibiotic use is a relevant risk factor for MRSA colonization in patients undergoing primary total hip arthroplasty.
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Affiliation(s)
- Daniel Schweitzer
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Orthopedic Surgery, Santiago, Chile
| | - Ianiv Klaber
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Orthopedic Surgery, Santiago, Chile
| | - Patricia García
- Pontificia Universidad Católica de Chile, Department of Orthopedic Surgery, Santiago, Chile
| | - Felipe López
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Orthopedic Surgery, Santiago, Chile
| | - María Jesús Lira
- Pontificia Universidad Católica de Chile, Department of Clinical Laboratories, Santiago, Chile
| | - Eduardo Botello
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Orthopedic Surgery, Santiago, Chile
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McFarland A, Reilly J, Manoukian S, Mason H. The economic benefits of surgical site infection prevention in adults: a systematic review. J Hosp Infect 2020; 106:76-101. [PMID: 32417433 DOI: 10.1016/j.jhin.2020.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/11/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) present a significant burden to healthcare and patients in terms of excess length of stay, distress, disability and death. SSI risk and the associated economic burden may be reduced through adherence to prevention guidelines although the irreducible minimum is unclear. AIM To evaluate the methods used to estimate the cost-effectiveness of prevention strategies for all SSIs. METHODS PubMed, Medline, CINAHL, and UK National Health Service Economic Evaluation Database were searched from inception to January 2020 to identify English language economic evaluation studies, embedded economic evaluations, and studies with some analysis in relation to cost and benefit in adult patients receiving surgical care in any setting. Risk of bias was assessed using two published checklists. FINDINGS Thirty-two studies involving 24,043 participants were included. Most studies evaluated SSI prevention in orthopaedic surgeries. Antibiotic prophylaxis, screening, treating, or decolonization of meticillin-resistant Staphylococcus aureus and surgical wound closure were the main methods evaluated. Methods ranged from cost-analyses to cost-effectiveness and cost-utility analyses. Synthesis of results was not possible due to heterogeneity. All studies reported some economic benefit associated with preventing SSI; however, measures of benefit were not reported consistently and the quality of studies was low to moderate. Limited evidence in relation to SSI impact on quality of life was identified. CONCLUSION Current evidence in relation to the economic benefits of SSI prevention is limited. Further robust studies that utilize sound economic and epidemiological methods are required to inform future investment decisions in SSI prevention.
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Affiliation(s)
- A McFarland
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
| | - J Reilly
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - S Manoukian
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - H Mason
- Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Pritchard MG, Murphy J, Cheng L, Janarthanan R, Judge A, Leal J. Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence. BMJ Open 2020; 10:e032204. [PMID: 31948987 PMCID: PMC7044879 DOI: 10.1136/bmjopen-2019-032204] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work. DESIGN Systematic review of cost-utility analyses. DATA SOURCES Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019. ELIGIBILITY CRITERIA English-language peer-reviewed cost-utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis. DATA EXTRACTION AND SYNTHESIS Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration's tool to assess risk of bias. No quantitative synthesis was undertaken. RESULTS We identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation. CONCLUSIONS Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies. PROSPERO REGISTRATION NUMBER CRD42017059473.
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Affiliation(s)
- Mark G Pritchard
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jacqueline Murphy
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- Wolfson Institute of Preventive Medicine - Barts and the London, Queen Mary University of London, London, UK
| | - Lok Cheng
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Roshni Janarthanan
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Jose Leal
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
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Judge A, Carr A, Price A, Garriga C, Cooper C, Prieto-Alhambra D, Old F, Peat G, Murphy J, Leal J, Barker K, Underdown L, Arden N, Gooberman-Hill R, Fitzpatrick R, Drew S, Pritchard MG. The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system.
Objectives
To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement.
Design
(1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness.
Setting
Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England.
Participants
Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement.
Interventions
Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation).
Main outcome measures
Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years.
Results
Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole.
Limitations
Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors.
Conclusion
No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts.
Future work
There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals.
Study registration
This study is registered as PROSPERO CRD42017059473.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Judge
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Andrew Carr
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Price
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cesar Garriga
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Daniel Prieto-Alhambra
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
- GREMPAL Research Group, Musculoskeletal Research Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Jacqueline Murphy
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Karen Barker
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lydia Underdown
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel Arden
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Rachael Gooberman-Hill
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sarah Drew
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark G Pritchard
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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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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Abstract
OBJECTIVE The objective of this study was to evaluate if a preoperative wellness bundle significantly decreases the risk of hospital acquired infections (HAI). BACKGROUND HAI threaten patient outcomes and are a significant burden to the healthcare system. Preoperative wellness efforts may significantly decrease the risk of infections. METHODS A group of 12,396 surgical patients received a wellness bundle in a roller bag during preoperative screening at an urban academic medical center. The wellness bundle consisted of a chlorhexidine bath solution, immuno-nutrition supplements, incentive spirometer, topical mupirocin for the nostrils, and smoking cessation information. Study staff performed structured patient interviews, observations, and standardized surveys at key intervals throughout the perioperative period. Statistics compare HAI outcomes of patients in the wellness program to a nonintervention group using the Fisher's exact test, logistic regression, and Poisson regression. RESULTS Patients in the nonintervention and intervention groups were similar in demographics, comorbidity, and type of operations. Compliance with each element was high (80% mupirocin, 72% immuno-nutrition, 71% chlorhexidine bath, 67% spirometer). The intervention group had statistically significant reductions in surgical site infections, Clostridium difficile, catheter associated urinary tract infections, and patient safety indicator 90. CONCLUSIONS A novel, preoperative, patient-centered wellness program dramatically reduced HAI in surgical patients at an urban academic medical center.
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Teja BJ, Sutherland TN, Barnett SR, Talmor DS. Cost-Effectiveness Research in Anesthesiology. Anesth Analg 2019; 127:1196-1201. [PMID: 29570150 DOI: 10.1213/ane.0000000000003334] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative interventions aimed at decreasing costs and improving outcomes have become increasingly popular in recent years. Anesthesiologists are often faced with a choice among different treatment strategies with little data available on the comparative cost-effectiveness. We performed a systematic review of the English language literature between 1980 and 2014 to identify cost-effectiveness analyses of anesthesiology and perioperative medicine interventions. We excluded interventions related to critical care or pediatric anesthesiology, and articles on interventions not normally ordered or performed by anesthesiologists. Of the >5000 cost-effectiveness analyses published to date, only 28 were applicable to anesthesiology and perioperative medicine and met inclusion criteria. Multidisciplinary interventions were the most cost-effective overall; 8 of 8 interventions were "dominant" (improved outcomes, reduced cost) or cost-effective, including accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles. Intraoperative measures were dominant in 3 of 5 cases, including spinal anesthesia for benign abdominal hysterectomy. With regard to prevention of perioperative infection, methicillin-resistant Staphylococcus aureus (MRSA) decolonization was dominant or cost-effective in 2 of 2 studies. Three studies assessing various antibiotic prophylaxis regimens had mixed results. Autologous blood donation was not found to be cost-effective in 5 of 7 studies, and intraoperative cell salvage therapy was also not cost-effective in 2 of 2 reports. Overall, there remains a paucity of cost-effectiveness literature in anesthesiology, particularly relating to intraoperative interventions and multidisciplinary perioperative interventions. Based on the available studies, multidisciplinary perioperative optimization interventions such as accelerated, standardized perioperative recovery pathways, and perioperative delirium prevention bundles tended to be most cost-effective. Our review demonstrates that there is a need for more rigorous cost-effective analyses in many areas of anesthesiology and that anesthesiologists should continue to lead collaborative, multidisciplinary efforts in perioperative medicine.
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Affiliation(s)
- Bijan J Teja
- From the Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tori N Sutherland
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Sheila R Barnett
- From the Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel S Talmor
- From the Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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Matza LS, Kim KJ, Yu H, Belden KA, Chen AF, Kurd M, Lee BY, Webb J. Health state utilities associated with post-surgical Staphylococcus aureus infections. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:819-827. [PMID: 30887157 PMCID: PMC6652168 DOI: 10.1007/s10198-019-01036-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/08/2019] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Surgical site infections (SSIs) are among the most common and potentially serious complications after surgery. Staphylococcus aureus is a virulent pathogen frequently identified as a cause of SSI. As vaccines and other infection control measures are developed to reduce SSI risk, cost-utility analyses (CUA) of these interventions are needed to inform resource allocation decisions. A recent systematic review found that available SSI utilities are of "questionable quality." Therefore, the purpose of this study was to estimate the disutility (i.e., utility decrease) associated with SSIs. METHODS In time trade-off interviews, general population participants in the UK (London, Edinburgh) valued health states drafted based on literature and clinician interviews. Health states described either joint or spine surgery, with or without an SSI. The utility difference between otherwise identical health states with and without the SSI represented the disutility associated with the SSI. RESULTS A total of 201 participants completed interviews (50.2% female; mean age = 46.2 years). Mean (SD) utilities of health states describing joint and spine surgery without infections were 0.79 (0.23) and 0.78 (0.23). Disutilities of SSIs ranged from - 0.03 to - 0.32, depending on severity of the infection and subsequent medical interventions. All differences between corresponding health with and without SSIs were statistically significant (all p < 0.001). CONCLUSION The preference-based SSI disutilities derived in this study may be used to represent mild and serious SSIs in CUAs assessing and comparing the value of vaccinations that may reduce the risk of SSIs.
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Affiliation(s)
- Louis S. Matza
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Katherine J. Kim
- Evidera, 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD 20814 USA
| | - Holly Yu
- Pfizer Inc, Collegeville, PA USA
| | - Katherine A. Belden
- Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Antonia F. Chen
- Department of Orthopaedics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mark Kurd
- Department of Orthopedic Surgery Sidney Kimmel Medical College, Thomas Jefferson University The Rothman Institute, Philadelphia, PA USA
| | - Bruce Y. Lee
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Jason Webb
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Rennert-May E, Conly J, Smith S, Puloski S, Henderson E, Au F, Manns B. A cost-effectiveness analysis of mupirocin and chlorhexidine gluconate for Staphylococcus aureus decolonization prior to hip and knee arthroplasty in Alberta, Canada compared to standard of care. Antimicrob Resist Infect Control 2019; 8:113. [PMID: 31338160 PMCID: PMC6625116 DOI: 10.1186/s13756-019-0568-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/04/2019] [Indexed: 12/29/2022] Open
Abstract
Background While decolonization of Staphylococcus aureus reduces surgical site infection (SSI) rates following hip and knee arthroplasty, its cost-effectiveness is uncertain. We sought to examine the cost-effectiveness of a decolonization protocol for Staphylococcus aureus prior to hip and knee replacement in Alberta compared to standard care – no decolonization. Methods Decision analytic models and a probabilistic sensitivity analysis were used for a cost-effectiveness analysis, with the effectiveness of decolonization based on a large published pre- and post- intervention trial. The primary outcomes of the models were infections prevented and health care costs. We modelled the cost-effectiveness of decolonization in a hypothetical cohort of adult patients undergoing hip and knee replacement in Alberta, Canada. Information on the incidence of complex surgical site infections (SSIs), as well as the cost of care for patients with and without SSIs was taken from a provincial infection control database, and health administrative data. Results Use of the decolonization bundle was cost saving compared to usual care ($153/person), and resulted in 16 complex Staphylococcus aureus SSIs annually as opposed to 32 (with approximately 8000 hip or knee arthroplasties performed). The probabilistic sensitivity analysis demonstrated that the majority (84%) of the time the decolonization bundle was cost saving. The model was robust to one-way sensitivity analyses conducted within plausible ranges. There were small upfront costs associated with using a decolonization protocol, however, this model demonstrated cost savings over one year. In a Markov model that considered the impact of a decolonization bundle over a lifetime as it pertained to the need for subsequent joint replacements and patient quality of life, the bundle still resulted in cost savings ($161/person). Conclusions Decolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures. Electronic supplementary material The online version of this article (10.1186/s13756-019-0568-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elissa Rennert-May
- 1Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - John Conly
- 2Departments of Medicine; Microbiology, Immunology and Infectious Diseases; Pathology and Laboratory Medicine, O'Brien Institute for Public Health; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada
| | - Stephanie Smith
- 3Department of Medicine, University of Alberta, Edmonton, Canada
| | - Shannon Puloski
- 4Department of Surgery, University of Calgary, Calgary, Canada
| | - Elizabeth Henderson
- 5Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Flora Au
- 6Department of Medicine, University of Calgary, Calgary, Canada
| | - Braden Manns
- 7Departments of Medicine and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute, University of Calgary, HRIC Building, 2500 University Drive NW, Calgary, AB T2N1N4 Canada
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Kerbel YE, Kirchner GJ, Sunkerneni AR, Lieber AM, Moretti VM. The Cost Effectiveness of Dilute Betadine Lavage for Infection Prophylaxis in Total Joint Arthroplasty. J Arthroplasty 2019; 34:S307-S311. [PMID: 30954409 DOI: 10.1016/j.arth.2019.02.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This article presents a break-even analysis for intraoperative Betadine lavage for the prevention of infection in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost effectiveness. RESULTS At our institutional price of $2.54, dilute (0.35%) Betadine lavage would be cost effective if initial infection rates of both TKA (1.10%) and THA (1.63%) have an ARR of 0.01%. At a hypothetical lowest cost of $0.50, the ARR is so low as to be immediately cost effective. At a hypothetical high price of $40.00, Betadine is cost effective with ARRs of 0.16% (TKA) and 0.13% (THA). CONCLUSION Intraoperative Betadine lavage, at typical institutional prices, can be highly cost effective in reducing infection after joint arthroplasty.
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Affiliation(s)
- Yehuda E Kerbel
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Gregory J Kirchner
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Anisha R Sunkerneni
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Alexander M Lieber
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Vincent M Moretti
- Department of Orthopaedic Surgery, Philadelphia Veteran's Affairs Hospital, The University of Pennsylvania, Philadelphia, PA
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Abstract
Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.
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Kline SE, Sanstead EC, Johnson JR, Kulasingam SL. Cost-effectiveness of pre-operative Staphylococcus aureus screening and decolonization. Infect Control Hosp Epidemiol 2018; 39:1340-1346. [PMID: 30231943 PMCID: PMC8559732 DOI: 10.1017/ice.2018.228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We developed a decision analytic model to evaluate the impact of a preoperative Staphylococcus aureus decolonization bundle on surgical site infections (SSIs), health-care-associated costs (HCACs), and deaths due to SSI. METHODS Our model population comprised US adults undergoing elective surgery. We evaluated 3 self-administered preoperative strategies: (1) the standard of care (SOC) consisting of 2 disinfectant soap showers; (2) the "test-and-treat" strategy consisting of the decolonization bundle including chlorhexidine gluconate (CHG) soap, CHG mouth rinse, and mupirocin nasal ointment for 5 days) if S. aureus was found at any of 4 screened sites (nasal, throat, axillary, perianal area), otherwise the SOC; and (3) the "treat-all" strategy consisting of the decolonization bundle for all patients, without S. aureus screening. Model parameters were derived primarily from a randomized controlled trial that measured the efficacy of the decolonization bundle for eradicating S. aureus. RESULTS Under base-case assumptions, the treat-all strategy yielded the fewest SSIs and the lowest HCACs, followed by the test-and-treat strategy. In contrast, the SOC yielded the most SSIs and the highest HCACs. Consequently, relative to the SOC, the average savings per operation was $217 for the treat-all strategy and $123 for the test-and-treat strategy, and the average savings per per SSI prevented was $21,929 for the treat-all strategy and $15,166 for the test-and-treat strategy. All strategies were sensitive to the probability of acquiring an SSI and the increased risk if SSI if the patient was colonized with SA. CONCLUSION We predict that the treat-all strategy would be the most effective and cost-saving strategy for preventing SSIs. However, because this strategy might select more extensively for mupirocin-resistant S. aureus and cause more medication adverse effects than the test-and-treat approach or the SOC, additional studies are needed to define its comparative benefits and harms.
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Affiliation(s)
- Susan E Kline
- 1Division of Infectious Diseases,Department of Medicine, University of Minnesota Medical School,Minneapolis,Minnesota
| | - Erinn C Sanstead
- 2Division of Epidemiology, University of Minnesota School of Public Health,Minneapolis,Minnesota
| | - James R Johnson
- 1Division of Infectious Diseases,Department of Medicine, University of Minnesota Medical School,Minneapolis,Minnesota
| | - Shalini L Kulasingam
- 2Division of Epidemiology, University of Minnesota School of Public Health,Minneapolis,Minnesota
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Purba AKR, Setiawan D, Bathoorn E, Postma MJ, Dik JWH, Friedrich AW. Prevention of Surgical Site Infections: A Systematic Review of Cost Analyses in the Use of Prophylactic Antibiotics. Front Pharmacol 2018; 9:776. [PMID: 30072898 PMCID: PMC6060435 DOI: 10.3389/fphar.2018.00776] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/26/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction: The preoperative phase is an important period in which to prevent surgical site infections (SSIs). Prophylactic antibiotic use helps to reduce SSI rates, leading to reductions in hospitalization time and cost. In clinical practice, besides effectiveness and safety, the selection of prophylactic antibiotic agents should also consider the evidence with regard to costs and microbiological results. This review assessed the current research related to the use of antibiotics for SSI prophylaxis from an economic perspective and the underlying epidemiology of microbiological findings. Methods: A literature search was carried out through PubMed and Embase databases from 1 January 2006 to 31 August 2017. The relevant studies which reported the use of prophylactic antibiotics, SSI rates, and costs were included for analysis. The causing pathogens for SSIs were categorized by sites of the surgery. The quality of reporting on each included study was assessed with the “Consensus on Health Economic Criteria” (CHEC). Results: We identified 20 eligible full-text studies that met our inclusion criteria, which were subsequently assessed, studies had in a reporting quality scored on the CHEC list averaging 13.03 (8–18.5). Of the included studies, 14 were trial-based studies, and the others were model-based studies. The SSI rates ranged from 0 to 71.1% with costs amounting to US$480-22,130. Twenty-four bacteria were identified as causative agents of SSIs. Gram negatives were the dominant causes of SSIs especially in general surgery, neurosurgery, cardiothoracic surgery, and obstetric cesarean sections. Conclusions: Varying results were reported in the studies reviewed. Yet, information from both trial-based and model-based costing studies could be considered in the clinical implementation of proper and efficient use of prophylactic antibiotics to prevent SSIs and antimicrobial resistance.
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Affiliation(s)
- Abdul K R Purba
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Didik Setiawan
- Unit of PharmacoEpidemiology & Pharmacoeconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Muhammadiyah Purwokerto, Purwokerto, Indonesia
| | - Erik Bathoorn
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Unit of PharmacoEpidemiology & Pharmacoeconomics (PE2), Department of Pharmacy, University of Groningen, Groningen, Netherlands.,Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, Netherlands
| | - Jan-Willem H Dik
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Kerbel YE, Sunkerneni AR, Kirchner GJ, Prodromo JP, Moretti VM. The Cost-Effectiveness of Preoperative Staphylococcus aureus Screening and Decolonization in Total Joint Arthroplasty. J Arthroplasty 2018; 33:S191-S195. [PMID: 29510950 DOI: 10.1016/j.arth.2018.01.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 01/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This article presents a break-even analysis for preoperative Staphylococcus aureus colonization screening and decolonization protocols in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost-effectiveness. RESULTS S aureus nasal screening ($144.07) was cost effective when initial infection rates of TKA (1.10%) and THA (1.63%) had an ARR of 0.56% and 0.45%, respectively. The most inexpensive decolonization treatment ($5.09) was cost effective with an ARR of 0.02% for both TKA and THA. The most expensive decolonization option ($37.67) was cost effective with ARRs of 0.15% (TKA) and 0.12% (THA). CONCLUSION Preoperative S aureus decolonization can be highly cost effective, whereas colonization screening requires excessively high reductions in infection rate.
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Affiliation(s)
- Yehuda E Kerbel
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Anisha R Sunkerneni
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Gregory J Kirchner
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - John P Prodromo
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
| | - Vincent M Moretti
- Department of Orthopaedic Surgery, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA
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[Prevention of postoperative infections : Risk factors and the current WHO guidelines in musculoskeletal surgery]. Unfallchirurg 2018; 120:472-485. [PMID: 28573554 DOI: 10.1007/s00113-017-0362-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite the many scientific and technological advances postoperative infection continues to be a large problem for trauma and orthopedic surgeons. Based on a review of the current literature, this study provides a comprehensive overview of the risk factors (RF) and possible preventive measures to control surgical site infections. METHODS Medline search and analysis from 1968-2017 (as of 01 March 2017). Selection of trauma and orthopedic relevant RFs and comparison with WHO recommendations (global guidelines for the prevention of surgical site infection, Nov. 2016). RESULTS Identification of 858 relevant articles from the last 50 years (1968-2017). Pooled postoperative rate of infection is 0.3% (hand surgery) and 19% (3rd degree open fractures). For open fractures, there is no clear tendency towards lower infection rates during the past five decades. Identification of 115 RF from three areas (patient-dependent RF, organizational and procedural RF, trauma- and surgery-dependent RF). The five most important RFs are body mass index over 35 kg/m2, increased duration of surgery, diabetes mellitus, increased blood glucose levels in the perioperative period also in the case of nondiabetic patients, and errors in the perioperative antibiotic prophylaxis. DISCUSSION Inconsistent definition of "infection", interaction of the RF and the different follow-up duration limit the meaningfulness of the study. CONCLUSION In the future, considerable efforts must be made in order to achieve a noticeable reduction in the rate of infection, especially in the case of high-risk patients.
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Abstract
INTRODUCTION We investigate the effectiveness of a comprehensive aseptic protocol in reducing surgical site infection (SSI) after hip arthroplasty in a single medical centre with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA). METHODS A prospectively collected database of all patients undergoing hip arthroplasty in a single centre between 2005 and 2011 was reviewed for SSI using Centers for Disease Control (CDC) criteria and AAOS guidelines. All patients were administered an aseptic protocol consisting of: preoperative 2% mupirocin nasal ointment and 0.4% chlorhexidine surgical-site wipes; modified instrument care; perioperative prophylactic vancomycin and cefazolin; and surgical-site skin preparation with chlorhexidine, alcohol and iodophor. We compare our protocol hip arthroplasty SSI rate to our institutional historical control and to contemporary literature. RESULTS Among 774 patients, 69% were ASA>2, 45% had BMI≥30 and 10.3% had rheumatoid arthritis. We found an overall 0.39% infection rate; significantly lower than our institutional historical control (0.39% vs. 2.60%, p<0.001, OR 0.15, NNT 200) and significantly lower than 6 published reports (p<0.001-0.022, OR 0.16-0.22). Compared to these cohorts, significantly more of our patients were ASA>2, had BMI≥30 or had rheumatoid arthritis. Patients with 3 or more identifiable risk factors were at an increased risk of SSI compared to those with 2 or fewer risk factors. CONCLUSIONS Our aseptic protocol decreases SSI in a high-risk population undergoing hip arthroplasty in a medical centre and community with a high prevalence of MRSA.
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Graves N, Wloch C, Wilson J, Barnett A, Sutton A, Cooper N, Merollini K, McCreanor V, Cheng Q, Burn E, Lamagni T, Charlett A. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess 2018; 20:1-144. [PMID: 27468732 DOI: 10.3310/hta20540] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND A deep infection of the surgical site is reported in 0.7% of all cases of total hip arthroplasty (THA). This often leads to revision surgery that is invasive, painful and costly. A range of strategies is employed in NHS hospitals to reduce risk, yet no economic analysis has been undertaken to compare the value for money of competing prevention strategies. OBJECTIVES To compare the costs and health benefits of strategies that reduce the risk of deep infection following THA in NHS hospitals. To make recommendations to decision-makers about the cost-effectiveness of the alternatives. DESIGN The study comprised a systematic review and cost-effectiveness decision analysis. SETTING 77,321 patients who had a primary hip arthroplasty in NHS hospitals in 2012. INTERVENTIONS Nine different treatment strategies including antibiotic prophylaxis, antibiotic-impregnated cement and ventilation systems used in the operating theatre. MAIN OUTCOME MEASURES Change in the number of deep infections, change in the total costs and change in the total health benefits in quality-adjusted life-years (QALYs). DATA SOURCES Literature searches using MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials were undertaken to cover the period 1966-2012 to identify infection prevention strategies. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. Orthopaedic surgeons and infection prevention experts were also consulted. REVIEW METHODS English-language papers only. The selection of evidence was by two independent reviewers. Studies were included if they were interventions that reported THA-related deep surgical site infection (SSI) as an outcome. Mixed-treatment comparisons were made to produce estimates of the relative effects of competing infection control strategies. RESULTS Twelve studies, six randomised controlled trials and six observational studies, involving 123,788 total hip replacements (THRs) and nine infection control strategies, were identified. The quality of the evidence was judged against four categories developed by the National Institute for Health and Care Excellence Methods for Development of NICE Public Health Guidance ( http://publications.nice.org.uk/methods-for-the-development-of-nice-public-health-guidance-third-edition-pmg4 ), accessed March 2012. All evidence was found to fit the two highest categories of 1 and 2. Nine competing infection control interventions [treatments (Ts) 1-9] were used in a cohort simulation model of 77,321 patients who had a primary THR in 2012. Predictions were made for cases of deep infection and total costs, and QALY outcomes. Compared with a baseline of T1 (no systemic antibiotics, plain cement and conventional ventilation) all other treatment strategies reduced risk. T6 was the most effective (systemic antibiotics, antibiotic-impregnated cement and conventional ventilation) and prevented a further 1481 cases of deep infection, and led to the largest annual cost savings and the greatest gains to QALYs. The additional uses of laminar airflow and body exhaust suits indicate higher costs and worse health outcomes. CONCLUSIONS T6 is an optimal strategy for reducing the risk of SSI following THA. The other strategies that are commonly used among NHS hospitals lead to higher cost and worse QALY outcomes. Policy-makers, therefore, have an opportunity to save resources and improve health outcomes. The effects of laminar air flow and body exhaust suits might be further studied if policy-makers are to consider disinvesting in these technologies. LIMITATIONS A wide range of evidence sources was synthesised and there is large uncertainty in the conclusions. FUNDING The National Institute for Health Research Health Technology Assessment programme and the Queensland Health Quality Improvement and Enhancement Programme (grant number 2008001769).
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Affiliation(s)
- Nicholas Graves
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Jennie Wilson
- College of Nursing, Midwifery and Healthcare, University of West London, London, UK
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Alex Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Katharina Merollini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Victoria McCreanor
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Qinglu Cheng
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Edward Burn
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia
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Hong JC, Saraswat MK, Ellison TA, Magruder JT, Crawford T, Gardner JM, Padula WV, Whitman GJ. Staphylococcus Aureus Prevention Strategies in Cardiac Surgery: A Cost-Effectiveness Analysis. Ann Thorac Surg 2018; 105:47-53. [DOI: 10.1016/j.athoracsur.2017.06.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/18/2017] [Accepted: 06/12/2017] [Indexed: 11/17/2022]
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Sveom DS, Otteman MK, Garvin KL. Improving Quality and Decreasing Cost by Reducing Re-admissions in Patients Undergoing Total Joint Arthroplasty. Curr Rev Musculoskelet Med 2017; 10:388-396. [PMID: 28755149 PMCID: PMC5577425 DOI: 10.1007/s12178-017-9424-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Total joint arthroplasty (TJA) has had an increased demand over the recent years. It is a successful procedure, and there are relatively few complications, but there is a high overall cost. There is a push to increase the quality of care, lessen complications, and decrease cost by reducing readmissions. This article will discuss the risk factors that can contribute to the complication and readmission rates following TJA. RECENT FINDINGS Several risk factors have been found to contribute to the complication and readmission rates following a TJA. It is important to understand these risk factors and mitigate them as much as possible in order to optimize the patient experience. There are risk factors that cannot be modified, and the treatment team as well as the patient should be made aware of these and account for them when making the decision whether to undergo elective primary TJA or not. In general, an increased number of risk factors is associated with increased complications and increased readmission rates. At our institution, we have used this knowledge to improve our outcomes and decrease costs. It is important to be mindful of risk factors for poor outcomes prior to performing TJA. This allows for the optimization of patients prior to undergoing surgery. This can lead to improved outcomes at a lower cost.
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Affiliation(s)
- Daniel S. Sveom
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
| | - Mary K. Otteman
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
| | - Kevin L. Garvin
- Department of Orthopaedic Surgery and Rehabilitation, 985640 Nebraska Medical Center, Omaha, NE 68198-5640 USA
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Williams DM, Miller AO, Henry MW, Westrich GH, Ghomrawi HMK. Cost-Effectiveness of Staphylococcus aureus Decolonization Strategies in High-Risk Total Joint Arthroplasty Patients. J Arthroplasty 2017; 32:S91-S96. [PMID: 28341280 DOI: 10.1016/j.arth.2017.01.050] [Citation(s) in RCA: 9] [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: 12/01/2016] [Revised: 01/16/2017] [Accepted: 01/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients. METHODS An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective. RESULTS Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective). CONCLUSION S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system.
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Affiliation(s)
- Devin M Williams
- Infectious Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York; Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Andy O Miller
- Infectious Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Michael W Henry
- Infectious Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Geoffrey H Westrich
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
| | - Hassan M K Ghomrawi
- Healthcare Research Institute, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York
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Recommendations for Methicillin-Resistant Staphylococcus aureus Prevention in Adult ICUs. Crit Care Med 2017; 45:1304-1310. [DOI: 10.1097/ccm.0000000000002484] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bessa GR, Quinto VP, Machado DC, Lipnharski C, Weber MB, Bonamigo RR, D'Azevedo PA. Staphylococcus aureus resistance to topical antimicrobials in atopic dermatitis. An Bras Dermatol 2017; 91:604-610. [PMID: 27828633 PMCID: PMC5087218 DOI: 10.1590/abd1806-4841.20164860] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/04/2015] [Indexed: 11/21/2022] Open
Abstract
Background Topical antimicrobial drugs are indicated for limited superficial pyodermitis
treatment, although they are largely used as self-prescribed medication for
a variety of inflammatory dermatoses, including atopic dermatitis.
Monitoring bacterial susceptibility to these drugs is difficult, given the
paucity of laboratory standardization. Objective To evaluate the prevalence of Staphylococcus aureus topical
antimicrobial drug resistance in atopic dermatitis patients. Methods We conducted a cross-sectional study of children and adults diagnosed with
atopic dermatitis and S. aureus colonization. We used
miscellaneous literature reported breakpoints to define S.
aureus resistance to mupirocin, fusidic acid, gentamicin,
neomycin and bacitracin. Results A total of 91 patients were included and 100 S. aureus
isolates were analyzed. All strains were methicillin-susceptible S.
aureus. We found a low prevalence of mupirocin and fusidic acid
resistance (1.1% and 5.9%, respectively), but high levels of neomycin and
bacitracin resistance (42.6% and 100%, respectively). Fusidic acid
resistance was associated with more severe atopic dermatitis, demonstrated
by higher EASI scores (median 17.8 vs 5.7, p=.009). Our results also
corroborate the literature on the absence of cross-resistance between the
aminoglycosides neomycin and gentamicin. Conclusions Our data, in a southern Brazilian sample of AD patients, revealed a low
prevalence of mupirocin and fusidic acid resistance of S.
aureus atopic eczema colonizer strains. However, for neomycin
and bacitracin, which are commonly used topical antimicrobial drugs in
Brazil, high levels of resistance were identified. Further restrictions on
the use of these antimicrobials seem necessary to keep resistance as low as
possible.
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Affiliation(s)
- Giancarlo Rezende Bessa
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil.,Universidade Luterana do Brasil (ULBRA) - Canoas (RS), Brazil
| | - Vanessa Petry Quinto
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
| | - Daiane Corrêa Machado
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
| | - Caroline Lipnharski
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
| | - Magda Blessmann Weber
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
| | - Renan Rangel Bonamigo
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
| | - Pedro Alves D'Azevedo
- Universidade Federal de Ciências da Saúde de Porto Alegre - UFCSPA - Porto Alegre (RS), Brazil
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Abstract
The increasing number of implantations will lead to more periprosthetic infections. Periprosthetic infections in patients with rheumatism, who are often undergoing immunosuppressive treatment, represent a challenge for the treating physicians. The optimal care and treatment therefore necessitate an interdisciplinary agreement between orthopedic surgeons, specialists for infections and rheumatologists.
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Mohamed N, Wang MY, Le Huec JC, Liljenqvist U, Scully IL, Baber J, Begier E, Jansen KU, Gurtman A, Anderson AS. Vaccine development to prevent Staphylococcus aureus surgical-site infections. Br J Surg 2017; 104:e41-e54. [PMID: 28121039 DOI: 10.1002/bjs.10454] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/27/2016] [Accepted: 11/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI. METHODS A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI. RESULTS A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI. CONCLUSION There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.
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Affiliation(s)
- N Mohamed
- Pfizer Vaccine Research and Development, Pearl River, New York, USA
| | - M Y Wang
- Departments of Neurological Surgery and Rehabilitation Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - J-C Le Huec
- Spine Unit 2, Surgical Research Laboratory, Bordeaux University Hospital, Bordeaux, France
| | - U Liljenqvist
- Department of Spine Surgery, St Franziskus Hospital Muenster, Münster, Germany
| | - I L Scully
- Pfizer Vaccine Research and Development, Pearl River, New York, USA
| | - J Baber
- Pfizer Vaccine Clinical Research and Development, Sydney, New South Wales, Australia
| | - E Begier
- Pfizer Vaccine Clinical Research and Development, Pearl River, New York, USA
| | - K U Jansen
- Pfizer Vaccine Research and Development, Pearl River, New York, USA
| | - A Gurtman
- Pfizer Vaccine Clinical Research and Development, Pearl River, New York, USA
| | - A S Anderson
- Pfizer Vaccine Research and Development, Pearl River, New York, USA
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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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Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty. J Arthroplasty 2017; 32:728-734.e1. [PMID: 27823845 DOI: 10.1016/j.arth.2016.09.041] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/25/2016] [Accepted: 09/24/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Staphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive. METHODS We reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a "screen and treat" program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs. RESULTS With a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA. CONCLUSION Our universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations.
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Strategies to Improve Total Knee Arthroplasty: A Multidisciplinary Research Conference. J Am Acad Orthop Surg 2017; 25 Suppl 1:S1-S3. [PMID: 27941416 DOI: 10.5435/jaaos-d-16-00633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Lefebvre J, Buffet-Bataillon S, Henaux P, Riffaud L, Morandi X, Haegelen C. Staphylococcus aureus screening and decolonization reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery. J Hosp Infect 2017; 95:144-147. [DOI: 10.1016/j.jhin.2016.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
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42
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Triple prophylaxis for the prevention of surgical site infections in total joint arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000454] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Küçükdurmaz F, Parvizi J. The Prevention of Periprosthetic Joint Infections. Open Orthop J 2016; 10:589-599. [PMID: 28144372 PMCID: PMC5226971 DOI: 10.2174/1874325001610010589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/12/2016] [Accepted: 07/15/2016] [Indexed: 12/14/2022] Open
Abstract
Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) adversely affects patient quality of life and health status, and places a huge financial burden on the health care. The first step in combating this complication is prevention, which may include implementation of strategies during the preoperative, intraoperative, or postoperative period. Optimization of the patient with appreciation of the modifiable and non-modifiable factors is crucial. Preoperative optimization involves medical optimization of patients with comorbidities such as diabetes, anemia, malnutrition and other conditions that may predispose the patient to PJI. Among the intraoperative strategies, administration of appropriate and timely antibiotics, blood conservation, gentle soft tissue handling, and expeditious surgery in an ultra clean operating room are among the most effective strategies. During the postoperative period, all efforts should be made to minimize ingress or proliferation of bacteria at the site of the index arthroplasty from draining the wound and hematoma formation. Although the important role of some preventative measures is known, further research is needed to evaluate the role of unproven measures that are currently employed and to devise further strategies for prevention of this feared complication.
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Affiliation(s)
- Fatih Küçükdurmaz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Humphreys H, Becker K, Dohmen P, Petrosillo N, Spencer M, van Rijen M, Wechsler-Fördös A, Pujol M, Dubouix A, Garau J. Staphylococcus aureus and surgical site infections: benefits of screening and decolonization before surgery. J Hosp Infect 2016; 94:295-304. [DOI: 10.1016/j.jhin.2016.06.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/06/2016] [Indexed: 12/13/2022]
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Abstract
Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.
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Predictors of Staphylococcus aureus Colonization and Results after Decolonization. Interdiscip Perspect Infect Dis 2016; 2016:4367156. [PMID: 27528869 PMCID: PMC4977396 DOI: 10.1155/2016/4367156] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/22/2016] [Indexed: 11/18/2022] Open
Abstract
Protocols for the screening and decolonization of Staphylococcus aureus prior to total joint arthroplasty (TJA) have become widely adopted. The goals of this study were to determine: (1) whether implementation of a screening protocol followed by decolonization with mupirocin/vancomycin and chlorhexidine reduces the risk of revision compared with no screening protocol (i.e., chlorhexidine alone) and (2) whether clinical criteria could reliably predict colonization with MSSA and/or MRSA. Electronic medical records of primary patients undergoing TJA that were screened (n = 3,927) and were not screened (n = 1,751) for Staphylococcus aureus at least 4 days prior to surgery, respectively, were retrospectively reviewed. All patients received chlorhexidine body wipes preoperatively. Patients carrying MSSA and MRSA were treated preoperatively with mupirocin and vancomycin, respectively, along with the standard preoperative antibiotics and chlorhexidine body wipes. Screened patients were 50% less likely to require revision due to prosthetic joint infection compared to those not screened (p = 0.04). Multivariate regression models were poorly accurate in predicting colonization with MSSA (AUC = 0.58) and MRSA (AUC = 0.62). These results support the routine screening and decolonization of S. aureus prior to TJA.
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Effectiveness of Decolonization With Chlorhexidine and Mupirocin in Reducing Surgical Site Infections. Dimens Crit Care Nurs 2016; 35:204-22. [DOI: 10.1097/dcc.0000000000000192] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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48
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McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am 2016; 98:e6. [PMID: 26791039 DOI: 10.2106/jbjs.n.00416] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obesity is associated with adverse outcomes and increased costs after total knee arthroplasty. Bariatric surgery is an effective treatment for morbid obesity, but its cost-effectiveness for weight loss prior to total knee arthroplasty is unknown. The purpose of this study was to evaluate the cost-effectiveness of bariatric surgery prior to total knee arthroplasty for patients in whom medical treatment of obesity and knee osteoarthritis had failed. METHODS A state-transition Markov model was constructed to compare the cost-utility of two treatment protocols for patients with morbid obesity and end-stage knee osteoarthritis: (1) immediate total knee arthroplasty and (2) bariatric surgery two years prior to the total knee arthroplasty. The probability of transition for each health state and its utility were derived from the literature. Costs, expressed in 2012 United States dollars, were estimated with use of administrative and claims data. Costs and utilities were discounted at 3% annually, and effectiveness was expressed in quality-adjusted life-years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed, using $100,000 per QALY as the threshold willingness to pay. RESULTS Morbidly obese patients undergoing total knee arthroplasty alone had lower QALYs gained than patients who underwent bariatric surgery two years prior to the total knee arthroplasty. The ICER between these two procedures was approximately $13,910 per QALY, well below the threshold willingness to pay. Results were stable across broad value ranges for independent variables. Probabilistic sensitivity analysis found that the median ICER was $14,023 per QALY (95% confidence interval, $4875 to $51,210 per QALY). CONCLUSIONS This model supports bariatric surgery prior to total knee arthroplasty as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis who are indicated for total knee arthroplasty. LEVEL OF EVIDENCE Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander S McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Daniel Southren
- Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032
| | - Y Claire Wang
- Department of Health Policy and Management, Columbia Mailman School of Public Health, 600 West 168th Street, 6th Floor, New York, NY 10032
| | - Robert G Marx
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Emily R Dodwell
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
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50
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Abstract
Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages. We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):27–30.
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Affiliation(s)
- M. R. Whitehouse
- University of Bristol, Southmead
Hospital, Bristol, BS10
5NB, UK
| | - M. C. Parry
- Royal Orthopaedic Hospital NHS Foundation
Trust, Bristol Road South, Birmingham, B31 2AP, UK
| | - S. Konan
- The University of British Columbia, 3rd
Floor, 910 West 10th Avenue, Vancouver, BC, V5Z
4E3, Canada
| | - C. P. Duncan
- The University of British Columbia, 3rd
Floor, 910 West 10th Avenue, Vancouver, BC, V5Z
4E3, Canada
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