Skip to main content
Top
Published in: Clinical Orthopaedics and Related Research® 6/2008

01-06-2008 | Symposium: Papers Presented at the 2007 Meeting of the Musculoskeletal Infection Society

A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections

Authors: Nalini Rao, MD, FACP, FSHEA, Barbara Cannella, RN, Lawrence S. Crossett, MD, A. J. Yates Jr, MD, Richard McGough III, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 6/2008

Login to get access

Abstract

Staphylococcus aureus (S. aureus) is an independent risk factor for orthopaedic surgical site infection (SSI). To determine whether a preoperative decolonization protocol reduces S. aureus SSIs, we conducted a prospective observational study of patients undergoing elective total joint arthroplasty (TJA) at our institution, with two control groups. The concurrent control group comprised patients of surgeons who did not participate in the intervention study. The preintervention control group comprised patients of participating surgeons who had undergone elective TJA during the year before the study. Patients in the intervention group were screened preoperatively for S. aureus by nasal swab cultures. S. aureus carriers were decolonized with mupirocin ointment to the nares twice daily and chlorhexidine bath once daily for 5 days before surgery. All 164 of 636 participants (26%) who tested positive completed the decolonization protocol without adverse events and had no postoperative S. aureus SSIs at 1-year followup. In contrast, 1330 concurrent control patients had 12 S. aureus infections. If these infections had occurred in the 26% of patients expected to be nasal carriers of S. aureus at a given time, the infection rate would have been 3.5% (12 of 345) in the control group. In addition, the overall infection rate of the participating surgeons, including nonstaphylococcal infections, decreased from 2.6% during the preintervention period to 1.5% during the intervention period, translating to an adjusted economic gain of $231,741 for the hospital. The data suggest a preoperative decolonization protocol reduces S. aureus SSIs in patients undergoing TJA.
Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Literature
1.
go back to reference Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol. 1990;11:89–93.PubMedCrossRef Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol. 1990;11:89–93.PubMedCrossRef
2.
go back to reference Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Ann Thorac Surg. 2001;71:1572–1578; discussion 1578–1579.PubMedCrossRef Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics. Ann Thorac Surg. 2001;71:1572–1578; discussion 1578–1579.PubMedCrossRef
3.
go back to reference D’Souza HA, Baron EJ. BBL CHROMagar Staph aureus is superior to mannitol salt for detection of Staphylococcus aureus in complex mixed infections. Am J Clin Pathol. 2005;123:806–808.PubMedCrossRef D’Souza HA, Baron EJ. BBL CHROMagar Staph aureus is superior to mannitol salt for detection of Staphylococcus aureus in complex mixed infections. Am J Clin Pathol. 2005;123:806–808.PubMedCrossRef
4.
go back to reference Flayhart D, Hindler JF, Bruckner DA, Hall G, Shrestha RK, Vogel SA, Richter SS, Howard W, Walther R, Carroll KC. Multicenter evaluation of BBL CHROMagar MRSA medium for direct detection of methicillin-resistant Staphylococcus aureus from surveillance cultures of the anterior nares. J Clin Microbiol. 2005;43:5536–5540.PubMedCrossRef Flayhart D, Hindler JF, Bruckner DA, Hall G, Shrestha RK, Vogel SA, Richter SS, Howard W, Walther R, Carroll KC. Multicenter evaluation of BBL CHROMagar MRSA medium for direct detection of methicillin-resistant Staphylococcus aureus from surveillance cultures of the anterior nares. J Clin Microbiol. 2005;43:5536–5540.PubMedCrossRef
5.
go back to reference Gernaat-van der Sluis AJ, Hoogenboom-Verdegaal AM, Edixhoven PJ, Spies-van Rooijen NH. Prophylactic mupirocin could reduce orthopedic wound infections. 1,044 patients treated with mupirocin compared with 1,260 historical controls. Acta Orthop Scand. 1998;69:412–414.CrossRef Gernaat-van der Sluis AJ, Hoogenboom-Verdegaal AM, Edixhoven PJ, Spies-van Rooijen NH. Prophylactic mupirocin could reduce orthopedic wound infections. 1,044 patients treated with mupirocin compared with 1,260 historical controls. Acta Orthop Scand. 1998;69:412–414.CrossRef
6.
go back to reference Hervey SL, Purves HR, Guller U, Toth AP, Vail TP, Pietrobon R. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-Nationwide Inpatient Sample. J Bone Joint Surg Am. 2003;85:1775–1783.PubMed Hervey SL, Purves HR, Guller U, Toth AP, Vail TP, Pietrobon R. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-Nationwide Inpatient Sample. J Bone Joint Surg Am. 2003;85:1775–1783.PubMed
7.
go back to reference Herwaldt LA. Reduction of Staphylococcus aureus nasal carriage, infection in dialysis patients. J Hosp Infect. 1998;40 Suppl B:S13–23.PubMedCrossRef Herwaldt LA. Reduction of Staphylococcus aureus nasal carriage, infection in dialysis patients. J Hosp Infect. 1998;40 Suppl B:S13–23.PubMedCrossRef
8.
go back to reference Irizarry L, Rupp J, Griffith J. Frequency of high-level mupirocin-resistant Staphylococcus aureus in a tertiary care facility. Antimicrob Agents Chemother. 1996;40:1967–1968.PubMed Irizarry L, Rupp J, Griffith J. Frequency of high-level mupirocin-resistant Staphylococcus aureus in a tertiary care facility. Antimicrob Agents Chemother. 1996;40:1967–1968.PubMed
9.
go back to reference Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, van Belkum A, Kluytmans JA. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35:353–358.PubMedCrossRef Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, van Belkum A, Kluytmans JA. Surgical site infections in orthopedic surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study. Clin Infect Dis. 2002;35:353–358.PubMedCrossRef
10.
go back to reference Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol. 2000;21:319–323.PubMedCrossRef Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GA. Nasal carriage of Staphylococcus aureus is a major risk factor for surgical-site infections in orthopedic surgery. Infect Control Hosp Epidemiol. 2000;21:319–323.PubMedCrossRef
11.
go back to reference Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10:505–520.PubMed Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev. 1997;10:505–520.PubMed
12.
go back to reference Kluytmans JA, Manders MJ, van Bommel E, Verbrugh H. Elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients. Infect Control Hosp Epidemiol. 1996;17:793–797.PubMed Kluytmans JA, Manders MJ, van Bommel E, Verbrugh H. Elimination of nasal carriage of Staphylococcus aureus in hemodialysis patients. Infect Control Hosp Epidemiol. 1996;17:793–797.PubMed
13.
go back to reference Kluytmans JA, Mouton JW, VandenBergh MF, Manders MJ, Maat AP, Wagenvoort JH, Michel MF, Verbrugh HA. Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol. 1996;17:780–785.PubMedCrossRef Kluytmans JA, Mouton JW, VandenBergh MF, Manders MJ, Maat AP, Wagenvoort JH, Michel MF, Verbrugh HA. Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol. 1996;17:780–785.PubMedCrossRef
14.
go back to reference Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64:162–168.PubMedCrossRef Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect. 2006;64:162–168.PubMedCrossRef
15.
go back to reference Leski TA, Gniadkowski M, Skoczynska A, Stefaniuk E, Trzcinski K, Hryniewicz W. Outbreak of mupirocin-resistant staphylococci in a hospital in Warsaw, Poland, due to plasmid transmission and clonal spread of several strains. J Clin Microbiol. 1999;37:2781–2788.PubMed Leski TA, Gniadkowski M, Skoczynska A, Stefaniuk E, Trzcinski K, Hryniewicz W. Outbreak of mupirocin-resistant staphylococci in a hospital in Warsaw, Poland, due to plasmid transmission and clonal spread of several strains. J Clin Microbiol. 1999;37:2781–2788.PubMed
16.
go back to reference Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2003;85:27–32.PubMed Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am. 2003;85:27–32.PubMed
17.
go back to reference Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250–278; quiz 279–280.PubMedCrossRef Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250–278; quiz 279–280.PubMedCrossRef
18.
go back to reference Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol. 1996;17:811–813.PubMed Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol. 1996;17:811–813.PubMed
19.
go back to reference National Nosocomial Infections Surveillance (NNIS) System report, data summary from October 1986-April 1998, issued June 1998. Am J Infect Control. 1998;26:522–533. National Nosocomial Infections Surveillance (NNIS) System report, data summary from October 1986-April 1998, issued June 1998. Am J Infect Control. 1998;26:522–533.
20.
go back to reference Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134:S10–17.PubMedCrossRef Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional perioperative prophylaxis. Surgery. 2003;134:S10–17.PubMedCrossRef
21.
go back to reference Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, Pfaller MA, Sheppard D, Twombley J, French PP, Herwaldt LA. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346:1871–1877.PubMedCrossRef Perl TM, Cullen JJ, Wenzel RP, Zimmerman MB, Pfaller MA, Sheppard D, Twombley J, French PP, Herwaldt LA. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med. 2002;346:1871–1877.PubMedCrossRef
22.
go back to reference Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother. 1998;32:S7–16.PubMed Perl TM, Golub JE. New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage. Ann Pharmacother. 1998;32:S7–16.PubMed
23.
go back to reference Sandri AM, Dalarosa MG, Ruschel de Alcantara L, da Silva Elias L, Zavascki AP. Reduction in incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in an intensive care unit: role of treatment with mupirocin ointment and chlorhexidine baths for nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27:185–187.PubMedCrossRef Sandri AM, Dalarosa MG, Ruschel de Alcantara L, da Silva Elias L, Zavascki AP. Reduction in incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in an intensive care unit: role of treatment with mupirocin ointment and chlorhexidine baths for nasal carriers of MRSA. Infect Control Hosp Epidemiol. 2006;27:185–187.PubMedCrossRef
24.
go back to reference Sculco TP. The economic impact of infected total joint arthroplasty. Instr Course Lect. 1993;42:349–351.PubMed Sculco TP. The economic impact of infected total joint arthroplasty. Instr Course Lect. 1993;42:349–351.PubMed
25.
go back to reference Simor AE, Phillips E, McGeer A, Konvalinka A, Loeb M, Devlin HR, Kiss A. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44:178–185.PubMedCrossRef Simor AE, Phillips E, McGeer A, Konvalinka A, Loeb M, Devlin HR, Kiss A. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44:178–185.PubMedCrossRef
26.
go back to reference Suzuki Y, Kamigaki T, Fujino Y, Tominaga M, Ku Y, Kuroda Y. Randomized clinical trial of preoperative intranasal mupirocin to reduce surgical-site infection after digestive surgery. Br J Surg. 2003;90:1072–1075.PubMedCrossRef Suzuki Y, Kamigaki T, Fujino Y, Tominaga M, Ku Y, Kuroda Y. Randomized clinical trial of preoperative intranasal mupirocin to reduce surgical-site infection after digestive surgery. Br J Surg. 2003;90:1072–1075.PubMedCrossRef
27.
go back to reference Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis. 2003;37:1629–1638.PubMedCrossRef Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis. 2003;37:1629–1638.PubMedCrossRef
28.
go back to reference Upton A, Lang S, Heffernan H. Mupirocin and Staphylococcus aureus: a recent paradigm of emerging antibiotic resistance. J Antimicrob Chemother. 2003;51:613–617.PubMedCrossRef Upton A, Lang S, Heffernan H. Mupirocin and Staphylococcus aureus: a recent paradigm of emerging antibiotic resistance. J Antimicrob Chemother. 2003;51:613–617.PubMedCrossRef
29.
go back to reference Watanakunakorn C, Brandt J, Durkin P, Santore S, Bota B, Stahl CJ. The efficacy of mupirocin ointment and chlorhexidine body scrubs in the eradication of nasal carriage of Staphylococcus aureus among patients undergoing long-term hemodialysis. Am J Infect Control. 1992;20:138–141.PubMedCrossRef Watanakunakorn C, Brandt J, Durkin P, Santore S, Bota B, Stahl CJ. The efficacy of mupirocin ointment and chlorhexidine body scrubs in the eradication of nasal carriage of Staphylococcus aureus among patients undergoing long-term hemodialysis. Am J Infect Control. 1992;20:138–141.PubMedCrossRef
30.
go back to reference Wendt C, Schinke S, Wurttemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007;28:1036–1043.PubMedCrossRef Wendt C, Schinke S, Wurttemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol. 2007;28:1036–1043.PubMedCrossRef
31.
go back to reference Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hosp Infect. 1995;31:13–24.PubMedCrossRef Wenzel RP, Perl TM. The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection. J Hosp Infect. 1995;31:13–24.PubMedCrossRef
32.
go back to reference Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23:183–189.PubMedCrossRef Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002;23:183–189.PubMedCrossRef
Metadata
Title
A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections
Authors
Nalini Rao, MD, FACP, FSHEA
Barbara Cannella, RN
Lawrence S. Crossett, MD
A. J. Yates Jr, MD
Richard McGough III, MD
Publication date
01-06-2008
Publisher
Springer-Verlag
Published in
Clinical Orthopaedics and Related Research® / Issue 6/2008
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI
https://doi.org/10.1007/s11999-008-0225-4

Other articles of this Issue 6/2008

Clinical Orthopaedics and Related Research® 6/2008 Go to the issue

Orthopaedic • Radiology • Pathology Conference

A Slow-growing Prepatellar Mass in a 31-year-old Woman

Symposium: Papers Presented at the 2007 Meeting of the Musculoskeletal Infection Society

Increased Oxacillin Resistance in Thigh Pyomyositis in Diabetic Patients

Symposium: Papers Presented at the 2007 Meeting of the Musculoskeletal Infection Society

Chitosan Films: A Potential Local Drug Delivery System for Antibiotics

Symposium: Selected Papers Presented at the 2007 Meeting of the Musculoskeletal Tumor Society

Mirels’ Rating for Humerus Lesions is Both Reproducible and Valid

Case Report

Case Report

Symposium: Selected Papers Presented at the 2007 Meeting of the Musculoskeletal Tumor Society

A Comparison of Intramedullary and Juxtacortical Low-grade Osteogenic Sarcoma