What is the most cost-effective strategy for nasal screening and Staphylococcus aureus decolonization in patients undergoing total hip arthroplasty?

Current Concepts on the Clinical and Economic Impact of Periprosthetic Joint Infections

Total joint arthroplasty (TJA) is a common procedure performed throughout the entire world in hopes of alleviating debilitating hip or knee pain. The projected number of TJAs performed in the United States alone is projected to exceed 1.9 million by 2030 and 5 million by 2040. With the significant increase in TJA performed, more periprosthetic joint infections (PJIs) are likely to be encountered. PJIs are a devastating complication of TJA. The economic and clinical burden must be understood and respected to minimize occurrence and allow optimal patient outcomes.

Diagnosis and Prevention of Periprosthetic Joint Infections by Staphylococcus aureus after Hip Fracture: A Systematic Review of the Literature

Hip arthroplasties are surgical procedures widely performed all over the world, seeking to return functionality, relieve pain, and improve the quality of life of patients affected by osteoarthritis, femoral neck fractures, osteonecrosis of the femoral head, among other etiologies. Periprosthetic joint infections are one of the most feared complications due to the high associated morbidity and mortality, with a high number of pathogens that may be associated with its etiology. The aim of the present study was to analyze aspects correlated with the occurrence of infection, diagnosis and prevention of periprosthetic joint infections in the hip associated with Staphylococcus aureus after corrective surgery for hip fractures. This is a systematic review of the literature carried out in the databases indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) carried out in accordance with the precepts established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Twenty studies that addressed the diagnosis and prevention of periprosthetic joint infections after hip fractures were selected for analysis. It is observed that there is no consensus in the literature on preventive measures for the occurrence of such infectious processes. Among the risk factors for the occurrence and severity of infections by S. aureus after hip arthroplasties, obesity, longer surgical time, older age, immunosuppression, recent use of antibiotics, and multicomorbidities were mentioned. The use of biomarkers for early diagnosis, as well as screening, decolonization, and antibiotic prophylaxis processes are among the preventive procedures proposed in the literature.

Increased prevalence of Staphylococcus aureus nasal carriage in rheumatoid arthritis patients with moderate/high disease activity

BACKGROUND

Staphylococcus aureus (S. aureus) nasal carriage is a well-known risk factor for surgical site infection (SSI) after total joint arthroplasty. This study aimed to compare the prevalence of S. aureus nasal carriage between patients with osteoarthritis (OA), a degenerative joint disease, and those with rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease, who underwent total joint arthroplasty, and to investigate the influence of RA disease activity on nasal carriage rate.

METHODS

This retrospective study targeted 508 OA and 107 RA patients who underwent S. aureus nasal screening prior to primary total knee and/or hip arthroplasty. RA patients were divided into two groups based on disease activity: the remission/low disease activity (REM/LDA) group and the moderate/high disease activity (MDA/HDA) group. Factors associated with S. aureus nasal carriage were assessed with multivariate logistic regression models.

RESULTS

Of all 615 patients, 155 (25%) carried S. aureus in their nares. Compared to OA patients, RA patients had a significantly higher rate of S. aureus nasal carriage (24% vs. 33%, p = 0.049). Compared to the REM/LDA group (n = 39), the MDA/HDA group (n = 58) had a significantly higher rate of S. aureus nasal carriage (21% vs. 41%, p = 0.032). Multivariate analysis revealed that the MDA/HDA group, but not the REM/LDA group, had a significantly higher odds of S. aureus nasal carriage compared to the OA group (odds ratio: 2.76, 95% confidence interval: 1.07-7.12).

CONCLUSION

Preoperative nasal screening for S. aureus is beneficial, especially in RA patients with moderate/high disease activity.

Staphylococcus aureus colonization and periprosthetic joint infection in patients undergoing elective total joint arthroplasty: a narrative review

Peri-prosthetic joint infections (PJIs) following total joint arthroplasty (TJA) are associated with higher treatment costs, longer hospital admissions and increased morbidity and mortality. Colonization with Staphylococcus aureus is an independent and modifiable risk factor for PJIs and carriers of S. aureus are ten times more likely than non-carriers for post-operative infections. Screening and targeted decolonization, vs universal decolonization without screening, remains a controversial topic. We recommend a tailored approach, based on local epidemiological patterns, resource availability and logistical capacity. Universal decolonization is associated with lower rates of SSI and may reduce treatment costs.

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

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

CONCLUSION

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