Top

Clinical Orthopaedics and Related Research®

Published in:

01-07-2013 | Survey

Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections

Authors: Antonia F. Chen, MD, MBA, Charles B. Wessel, MLS, Nalini Rao, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 7/2013

Abstract

Background

Staphylococcus aureus is the most common organism responsible for orthopaedic surgical site infections (SSIs). Patients who are carriers for methicillin-sensitive S. aureus or methicillin-resistant S. aureus (MRSA) have a higher likelihood of having invasive S. aureus infections. Although some have advocated screening for S. aureus and decolonizing it is unclear whether these efforts reduce SSIs.

Questions/purposes

The purposes of this study were to determine (1) whether S. aureus screening and decolonization reduce SSIs in orthopaedic patients and (2) if implementing this protocol is cost-effective.

Methods

Studies for this systematic review were identified by searching PubMed, which includes MEDLINE (1946–present), EMBASE.com (1974–present), and the Cochrane Library’s (John Wiley & Sons) Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTAD), and the NHS Economic Evaluation Database (NHSEED). Comprehensive literature searches were developed using EMTREE, MeSH, and keywords for each of the search concepts of decolonization, MRSA, and orthopedics/orthopedic surgery. Studies published before 1968 were excluded. We analyzed 19 studies examining the ability of the decolonization protocol to reduce SSIs and 10 studies detailing the cost-effectiveness of S. aureus screening and decolonization.

Results

All 19 studies showed a reduction in SSIs or wound complications by instituting a S. aureus screening and decolonization protocol in elective orthopaedic (total joints, spine, and sports) and trauma patients. The S. aureus screening and decolonization protocol also saved costs in orthopaedic patients when comparing the costs of screening and decolonization with the reduction of SSIs.

Conclusions

Preoperative screening and decolonization of S. aureus in orthopaedic patients is a cost-effective means to reduce SSIs.

Level of Evidence

Level IV, systematic review of Level I–IV studies. See the Guidelines for Authors for a complete description of levels of evidence.

Available only for authorised users

Ammerlaan HS, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009;48:922–930.PubMedCrossRef

Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, Sloane R, Sexton DJ. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009;4:e8305.PubMedCrossRef

Bengtsson S, Hambraeus A, Laurell G. Wound infections after surgery in a modern operating suite: clinical, bacteriological and epidemiological findings. J Hyg (Lond). 1979;83:41–57.CrossRef

Berthelot P, Grattard F, Cazorla C, Passot JP, Fayard JP, Meley R, Bejuy J, Farizon F, Pozzetto B, Lucht F. Is nasal carriage of Staphylococcus aureus the main acquisition pathway for surgical-site infection in orthopaedic surgery? Eur J Clin Microbiol Infect Dis. 2010;29:373–382.PubMedCrossRef

Bode LG, Kluytmans JA, Wertheim HF, Bogaers D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box AT, Voss A, van der Tweel I, van Belkum A, Verbrugh HA, Vos MC. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2010;362:9–17.PubMedCrossRef

Caffrey AR, Woodmansee SB, Crandall N, Tibert C, Fielding C, Mikolich DJ, Vezeridis MP, LaPlante KL. Low adherence to outpatient preoperative methicillin-resistant Staphylococcus aureus decolonization therapy. Infect Control Hosp Epidemiol. 2011;32:930–932.PubMedCrossRef

Chen AF, Chivukula S, Jacobs LJ, Tetreault MW, Lee JY. What is the prevalence of MRSA colonization in elective spine cases? Clin Orthop Relat Res. 2012;470:2684–2689.PubMedCrossRef

Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326:281–286.PubMedCrossRef

Coskun D, Aytac J. Decrease in Staphylococcus aureus surgical-site infection rates after orthopaedic surgery after intranasal mupirocin ointment. J Hosp Infect. 2004;58:90–91.PubMedCrossRef

10.

Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SR. Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol. 2012;33:152–159.PubMedCrossRef

11.

De Lucas-Villarrubia JC, Lopez-Franco M, Granizo JJ, De Lucas-Garcia JC, Gomez-Barrena E. Strategy to control methicillin-resistant Staphylococcus aureus post-operative infection in orthopaedic surgery. Int Orthop. 2004;28:16–20.PubMedCrossRef

12.

Edmundson SP, Hirpara KM, Bennett D. The effectiveness of methicillin-resistant Staphylococcus aureus colonisation screening in asymptomatic healthcare workers in an Irish orthopaedic unit. Eur J Clin Microbiol Infect Dis. 2011;30:1063–1066.PubMedCrossRef

13.

Engemann JJ, Carmeli Y, Cosgrove SE, Fowler VG, Bronstein MZ, Trivette SL, Briggs JP, Sexton DJ, Kaye KS. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. 2003;36:592–598.PubMedCrossRef

14.

Evans RP. Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review. Clin Orthop Relat Res. 2011;469:945–953.PubMedCrossRef

15.

Forward KR. The value of multiple surveillance cultures for methicillin-resistant Staphylococcus aureus. Am J Infect Control. 2010;38:596–599.PubMedCrossRef

16.

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.PubMedCrossRef

17.

Graber CJ, Schwartz BS. Failure of decolonization in patients with infections due to mupirocin-resistant strains of community-associated methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2008;29:284; author reply 284–285.PubMedCrossRef

18.

Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res. 2010;159:503–508.PubMedCrossRef

19.

Hacek DM, Robb WJ, Paule SM, Kudrna JC, Stamos VP, Peterson LR. Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection. Clin Orthop Relat Res. 2008;466:1349–1355.PubMedCrossRef

20.

Hadley S, Immerman I, Hutzler L, Slover J, Bosco J. Staphylococcus aureus decolonization protocol decreases surgical site infections for total joint replacement. Arthritis. 2010;2010:924518.PubMedCrossRef

21.

Harrop JS, Styliaras JC, Ooi YC, Radcliff KE, Vaccaro AR, Wu C. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20:94–101.PubMedCrossRef

22.

Hassan K, Koh C, Karunaratne D, Hughes C, Giles SN. Financial implications of plans to combat methicillin-resistant Staphylococcus aureus (MRSA) in an orthopaedic department. Ann R Coll Surg Engl. 2007;89:668–671.PubMedCrossRef

23.

Johnston P, Norrish AR, Brammar T, Walton N, Hegarty TA, Coleman NP. Reducing methicillin-resistant Staphylococcus aureus (MRSA) patient exposure by infection control measures. Ann R Coll Surg Engl. 2005;87:123–125.PubMedCrossRef

24.

Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol. 2005;26:916–922.PubMedCrossRef

25.

Kalmeijer MD, Coertjens H, De Baere GA, Stuurman A, Van Belkum A, Kluytmans JA. Postoperative wound infections in orthopedic surgery: the effect of mupirocine nasal ointment. Pharmaceutisch Weekblad. 2001;136:730–731.

26.

Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM, Bogaers-Hofman D, de Baere GA, Stuurman A, 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

27.

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

28.

Kaminski A, Kammler J, Wick M, Muhr G, Kutscha-Lissberg F. Transmission of methicillin-resistant Staphylococcus aureus among hospital staff in a German trauma centre: a problem without a current solution? J Bone Joint Surg Br. 2007;89:642–645.PubMed

29.

Kelly JC, O’Briain DE, Walls R, Lee SI, O’Rourke A, Mc Cabe JP. The role of pre-operative assessment and ringfencing of services in the control of methicillin resistant Staphlococcus aureus infection in orthopaedic patients. Surgeon. 2012;10:75–79.PubMedCrossRef

30.

Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, Hunter DJ, Martha JF, Miley GB, Parazin SJ, Dejoie P, Richmond JC. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92:1820–1826.PubMedCrossRef

31.

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

32.

Lauderdale KJ, Malone CL, Boles BR, Morcuende J, Horswill AR. Biofilm dispersal of community-associated methicillin-resistant Staphylococcus aureus on orthopedic implant material. J Orthop Res. 2010;28:55–61.PubMed

33.

Lautenbach E, Nachamkin I, Hu B, Fishman NO, Tolomeo P, Prasad P, Bilker WB, Zaoutis TE. Surveillance cultures for detection of methicillin-resistant Staphylococcus aureus: diagnostic yield of anatomic sites and comparison of provider- and patient-collected samples. Infect Control Hosp Epidemiol. 2009;30:380–382.PubMedCrossRef

34.

Lee BY, Wiringa AE, Bailey RR, Goyal V, Tsui B, Lewis GJ, Muder RR, Harrison LM. The economic effect of screening orthopedic surgery patients preoperatively for methicillin-resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2010;31:1130–1138.PubMedCrossRef

35.

Luna CM, Boyeras Navarro ID. Management of methicillin-resistant Staphylococcus aureus pneumonia. Curr Opin Infect Dis. 2010;23:178–184.PubMedCrossRef

36.

Nixon M, Jackson B, Varghese P, Jenkins D, Taylor G. Methicillin-resistant Staphylococcus aureus on orthopaedic wards: incidence, spread, mortality, cost and control. J Bone Joint Surg Br. 2006;88:812–817.PubMed

37.

Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J, Hedblom EC, Jacobson C, Smulders M, Gemmen E, Bharmal M. National trends in Staphylococcus aureus infection rates: impact on economic burden and mortality over a 6-year period (1998–2003). Clin Infect Dis. 2007;45:1132–1140.PubMedCrossRef

38.

Ostrander RV, Botte MJ, Brage ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am. 2005;87:980–985.PubMedCrossRef

39.

Patel N, Bagan B, Vadera S, Maltenfort MG, Deutsch H, Vaccaro AR, Harrop J, Sharan A, Ratliff JK. Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine. 2007;6:291–297.PubMedCrossRef

40.

Pofahl WE, Goettler CE, Ramsey KM, Cochran MK, Nobles DL, Rotondo MF. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg. 2009;208:981–986; discussion 986–988.PubMedCrossRef

41.

Portigliatti Barbos M, Mognetti B, Pecoraro S, Picco W, Veglio V. Decolonization of orthopedic surgical team S. aureus carriers: impact on surgical-site infections. J Orthop Traumatol. 2010;11:47–49.PubMedCrossRef

42.

Rao N, Cannella B, Crossett LS, Yates AJ Jr, McGough R 3rd. A preoperative decolonization protocol for staphylococcus aureus prevents orthopaedic infections. Clin Orthop Relat Res. 2008;466:1343–1348.PubMedCrossRef

43.

Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL 3rd, Hamilton CW. Preoperative screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26:1501–1507.PubMedCrossRef

44.

Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol. 2000;21:510–515.PubMedCrossRef

45.

Ro K. Methicillin-resistant Staphylococcus aureus colonization: a review of the literature on prevention and eradication. Advanced Emergency Nursing Journal. 2008;30(4):344–356.

46.

Rohr U, Wilhelm M, Muhr G, Gatermann S. Qualitative and (semi)quantitative characterization of nasal and skin methicillin-resistant Staphylococcus aureus carriage of hospitalized patients. Int J Hyg Environ Health. 2004;207:51–55.PubMedCrossRef

47.

Sankar B, Hopgood P, Bell KM. The role of MRSA screening in joint-replacement surgery. Int Orthop. 2005;29:160–163.PubMedCrossRef

48.

Slover J, Haas JP, Quirno M, Phillips MS, Bosco JA 3rd. Cost-effectiveness of a Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients. J Arthroplasty. 2011;26:360–365.PubMedCrossRef

49.

Sott AH, Jones R, Davies S, Cumberland N. The value of pre-operative screening for MRSA in the reduction of sepsis in total hip replacement associated with MRSA: a prospective audit. Hip Int. 2001;11:102–106.

50.

Tacconelli E, De Angelis G. Pneumonia due to methicillin-resistant Staphylococcus aureus: clinical features, diagnosis and management. Curr Opin Pulm Med. 2009;15:218–222.PubMedCrossRef

51.

van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;4:CD006216.PubMed

52.

van Rijen MM, Bode LG, Baak DA, Kluytmans JA, Vos MC. Reduced costs for staphylococcus aureus carriers treated prophylactically with mupirocin and chlorhexidine in cardiothoracic and orthopaedic surgery. PloS One. 2012;7:e43065.PubMedCrossRef

53.

Vincent JL. Nosocomial infections in adult intensive-care units. Lancet. 2003;361:2068–2077.PubMedCrossRef

54.

von Eiff C, Becker K, Machka K, Stammer H, Peters G. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344:11–16.CrossRef

55.

Wassenberg MW, de Wit GA, Bonten MJ. Cost-effectiveness of preoperative screening and eradication of staphylococcus aureus carriage. PloS One. 2011;6:e14815.PubMedCrossRef

56.

Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, Nouwen JL. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;5:751–762.PubMedCrossRef

57.

Wilcox MH, Hall J, Pike H, Templeton PA, Fawley WN, Parnell P, Verity P. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect. 2003;54:196–201.PubMedCrossRef

58.

Wilczynski NL, Haynes RB, Lavis JN, Ramkissoonsingh R, Arnold-Oatley AE, HSR Hedges team. Optimal search strategies for detecting health services research studies in MEDLINE. CMAJ. 2004;171:1179–1185.PubMed

59.

Wimmer C, Gluch H, Franzreb M, Ogon M. Predisposing factors for infection in spine surgery: a survey of 850 spinal procedures. J Spinal Disord. 1998;11:124–128.PubMed

60.

Zoabi M, Keness Y, Titler N, Bisharat N. Compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and its impact on rates of nosocomial MRSA bacteremia. Isr Med Assoc J. 2011;13:740–744.PubMed

Title: Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections
Authors: Antonia F. Chen, MD, MBA
Charles B. Wessel, MLS
Nalini Rao, MD
Publication date: 01-07-2013
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 7/2013
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-013-2875-0

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgery and Reduction of Surgical Site Infections

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 7/2013

Guest Editorial: Patriots’ Day at the Boston Marathon

Biographical Sketch: John Albert Key, 1890–1955

Comparison of the Cable Pin System With Conventional Open Surgery for Transverse Patella Fractures

Isoniazid Could Be Used for Antibiotic-loaded Bone Cement for Musculoskeletal Tuberculosis: An In Vitro Study

Severe Metal-induced Osteolysis Many Years After Unipolar Hip Endoprosthesis

Lateral Center-edge Angle on Conventional Radiography and Computed Tomography