Triple prophylaxis for the prevention of surgical site infections in total joint arthroplasty

Abstract

Background: Surgical site infection is a devastating complication and the most common mode of failure in total joint arthroplasty (TJA). The purpose of this study was to evaluate a unique triple prophylaxis protocol (preoperative nasal application of mupirocin, preoperative intravenous administration of vancomycin, and intraoperative betadine irrigation) in reducing surgical site infection rates in TJA. Methods: Our sample included 1034 consecutive patients who underwent primary hip or knee TJA for degenerative joint disease in the 2 yr prior to (control group) and 2 yr after institution of this protocol (treatment group). After follow-up of a minimum of 1 yr, we identified all patients who developed surgical site infection. We then calculated and compared the overall, superficial, deep, and methacillin-resistant Staphylococcus aureus (MRSA) surgical site infection rates between the control and treatment groups. Results: The overall surgical site infection rate decreased from 2.0% in our control cohort to 0.7% (P=0.08) in our treatment cohort. Rates of deep surgical site infection significantly decreased from 1.4% to 0.2% (P=0.02), but no change was observed in rates of superficial surgical site infection (0.6% to 0.6%, P=0.92). The rate of MRSA infection decreased from 0.6% to 0.2%, but this was not significant (P=0.28). Conclusions: We discovered that using this three-pronged prophylaxis approach for primary total knee and hip arthroplasties significantly decreased the rates of deep SSI compared to patients who did not receive these interventions. This protocol has the potential for changing the current protocol for preventing surgical site infection in future TJA.

Can nasal Staphylococcus aureus screening and decolonization prior to elective total joint arthroplasty reduce surgical site and prosthesis-related infections? A systematic review and meta-analysis

“…The most common methods of antibiotic prophylaxis were as follows: patients received a weightbased dose of cefazolin within 30-60 min before surgical incision and continued for 24 h postoperatively in both groups, while methicillin-resistant S. aureus (MRSA) carriers were treated with vancomycin 1 g at least 30 min before incision and every 12 h lasting for 24 h in screening group. However, in the study performed by Hofmann et al [37], all patients received 1 g of vancomycin preoperative in the screening group. In another study of Hacek et al [13], hip surgery patients were treated with cefazolin preoperatively while knee surgery patients were given vancomycin in the screening group.…”

“…The remaining 46 fulltext papers were then retrieved for a more detailed analysis, of which 37 papers were excluded for several reasons, such as irrelevant research (n = 18), lacking raw date (n = 4) [18][19][20][21], containing revision or other [20][21][22][23][24][25][26][27][28][29][30][31][32][33], and inaccessible language (n = 2) [34,35]. Finally, a total of nine studies were included in this research [4,[10][11][12][13][36][37][38][39]. Six of them were performed multivariate analysis [10-13, 37, 38], and the remaining three studies were given a descriptive analysis of findings because of slightly different intervention methods [4,36,39].…”

“…A total of 36041 joint replacements were included in the nine studies, of which 26226 were divided into S. aureus screening and decolonization group, and the remaining 9815 were the control group. Except for one study that only included TKA [10], all other studies included TKA and THA [4,[11][12][13][36][37][38][39]. Among the nine studies, six were from the USA [4, 11-13, 37, 38], two from the UK [36,39], and one from Spain [10].…”

“…The majority of studies included in this review used the diagnostic criteria of Center for Disease Control (CDC) and/or National Healthcare Safety Network (NHSN) for any wound complications [4,10,12,13,37], while Jeans et al [36] used the Public Health England's published standard, Sporer et al [38] diagnosed SSI based on clinical symptoms, positive wound culture, and a note in the medical record, while Rao et al [11] and Sankar et al [39] did not give a specific definition.…”

“…Six studies [10][11][12][13][36][37][38] that assessed 18549 TJA reported postoperative SSI. The pooled analyses demonstrated that S. aureus screening and decolonization prior to surgery decreased the risk of subsequent SSI (OR = 0.43, 95% CI 0.31 to 0.59, I 2 = 0%, p < 0.001; Fig.…”