Decolonization to reduce Staphylococcus aureus surgical site infections after hip or knee arthroplasty.
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ABSTRACT:
SUBMITTER: Everstz N
PROVIDER: S-EPMC9641506 | biostudies-literature | 2022
REPOSITORIES: biostudies-literature
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Decolonization to reduce <i>Staphylococcus aureus</i> surgical site infections after hip or knee arthroplasty.
Everstz Natalia N Marshall Caroline C Richards Matthew M Tong Steven Y C SYC
Antimicrobial stewardship & healthcare epidemiology : ASHE 20221104 1
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Project description:BackgroundNasal Staphylococcus aureus (S. aureus) screening and decolonization has been widely used to reduce surgical site infections (SSIs) prior to total knee and hip arthroplasty (TKA and THA). However, it remains considerably controversial. The aim of this study was to ascertain whether this scheme could reduce SSIs and periprosthetic joint infections (PJIs) following elective primary total joint arthroplasty (TJA).MethodsA systematic search was performed in MEDLINE, Embase, and the Cochrane Library until October, 2019. Outcomes of interest included SSI, PJI, superficial infection, and different bacterial species that caused infections. Data from eligible studies were then extracted and synthesized. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated. We also performed additional analyses to evaluate whether there were differences in postoperative SSIs caused by S. aureus or other bacteria.ResultsNine studies were included in our meta-analysis. The pooled data elucidated that nasal S. aureus screening and decolonization dramatically mitigated the risk of SSI, PJI, and superficial infection compared to nondecolonization group. The analysis of bacterial species causing infection also showed that the S. aureus infections postoperative were significantly decreased in the decolonization group. However, there was no statistical difference in the SSI caused by other bacteria between the two groups.ConclusionS. aureus screening and decolonization prior to elective primary THA and TKA could significantly decrease the risk of SSI and PJI. However, more robust studies are needed to further evaluate the impact of S. aureus screening and decolonization on infection risk after TJA.
| S-EPMC7031963 | biostudies-literature
Project description:BACKGROUND:Surgical site infections following total hip or knee arthroplasties have a reported rate of 0.49%-2.5% and can cause significant morbidity as well as tripling the cost of health care expenses. Both methicillin sensitive and methicillin resistant strains of Staphylococcus aureus surgical site infections have been established as a major risk factor for postoperative surgical site infections. S. aureus colonizes the nose, axillae, and perineal region in up to 20%-30% of individuals. Although the literature has reported a higher prevalence of methicillin resistant S. aureus in the South Asian population, routine preoperative screening and prophylaxis have not yet been implemented. OBJECTIVE:The primary objective of our study is to identify the relationship between preoperative colonization status of S. aureus and incidence of postoperative surgical site infections in patients undergoing following total hip and knee arthroplasties. As part of the secondary objectives of this study, we will also investigate patient characteristics acting as risk factors for S. aureus colonization as well as the outcomes of total hip and knee arthroplasty patients which are affected by surgical site infections. METHODS:This prospective cohort study will comprise of screening all patients older than 18 years of age admitted to the Aga Khan University Hospital for a primary total hip or knee arthroplasty for preoperative colonization with S. aureus. The patients will be followed postoperatively for up to one year following the surgery to assess the incidence of surgical site infections. The study duration will be 2 years (March 2018 to March 2020). For the purpose of screening, pooled swabs will be taken from the nose, axillae, and groin of each patient and inoculated in a brain heart infusion, followed by subculture onto mannitol salt agar and sheep blood agar. For methicillin resistant S. aureus identification, a cefoxitin disk screen will be done. Data will be analyzed using SPSS v23 and both univariate and multivariate regression analysis will be conducted. RESULTS:Data collection for this study will commence at the Aga Khan University Hospital, Pakistan during March 2018. CONCLUSIONS:This study will not only estimate the true burden caused by S. aureus in the population under study but will also help identify the patients at a high risk of surgical site infections so that appropriate interventions, including prophylaxis with antibiotics such as muciprocin ointment or linezolid, can be made. Given the differences in lifestyle, quality, and affordability of health care and the geographical variation in patterns of antibiotic resistance, this study will contribute significantly to providing incentive for routine screening and prophylaxis for S. aureus including methicillin resistant S. aureus colonization in the South Asian population. REGISTERED REPORT IDENTIFIER:RR1-10.2196/10219.
| S-EPMC6283255 | biostudies-literature
Project description:BackgroundSurgical site complications (SSCs) are the most common cause for readmission after total joint arthroplasty (TJA), increasing costs while predisposing to inferior long-term outcomes. Prophylactic use of closed-incision negative pressure therapy (ciNPT) may lower the risk of these complications, especially in high-risk populations, but appropriate-use guidelines are lacking for patients undergoing primary TJA. We sought to develop a risk-stratification algorithm to guide use of ciNPT dressings and test its use in normalizing the rate of superficial SSCs among high-risk groups.MethodsWe reviewed 323 consecutive primary TJAs, where 38% of those patients considered at elevated risk were risk-stratified to receive ciNPT dressings. An individual risk score was developed, assigning points based on patient-specific risk factors. We identified a historical control population of 643 patients who all received the same postoperative dressing to test the impact of this risk score.ResultsCompared with historical controls, we observed a modest but significant improvement in superficial SSCs after implementation of risk-stratification (12.0% vs 6.8%; P = .013). Among high-risk patients, there was a marked improvement in SSCs when treated prophylactically with ciNPT dressings as compared with historical controls (26.2% vs 7.3%; P < .001). Low-risk patients, who continued to be treated with standard postoperative dressings, demonstrated no significant improvement (8.6% vs 6.5%; P = .344).ConclusionsciNPT dressings are effective at reducing and normalizing risks of superficial SSCs among high-risk primary arthroplasty patients. The proposed risk-stratification algorithm may help identify those patients who benefit most from these dressings.
| S-EPMC6287286 | biostudies-literature
Project description:Arthroplasty is a common procedure improving functioning of patients and their quality of life. Infection is a serious complication that determines subsequent management of the prosthesis and the patient. The aim of the study was to investigate the incidence of post-discharge surgical site infections (SSI) and their risk factors. A retrospective analysis of an anonymized database from the National Health Found for 2017 of 56,068 adult patients undergoing hip replacement surgery (HPRO) and 27,457 patients undergoing knee replacement surgery (KPRO). The cumulative incidence of post-discharge SSI was 0.92% for HPRO and 0.95% for KPRO. The main risk factors for hip SSI were male gender, diseases of hematopoietic, musculoskeletal and nervous system. The risk factor for knee SSI was male gender. All comorbidities significantly increased the risk of SSI. The ICU stay and antibiotics administered at discharge in studied population increased the risk of detection of SSI after HPRO and KPRO by up to four and seven times, respectively. For both procedures rehabilitation after surgery and total endoprosthesis decreased incidence of SSIs. The lower experience of the center was related to higher SSI incidence in HPRO in primary (1.5% vs. 0.9%) and in revision surgeries (3.8% vs. 2.1%), but in KPRO, lower experience only in primary surgeries was significantly associated with SSI. The cumulative incidence of post-discharge SSI in Poland is higher than in other European countries. Special attention should be paid to patients with chronic diseases.
| S-EPMC10518305 | biostudies-literature
Project description:BackgroundQuality improvement (QI) campaigns appear to increase use of evidence-based practices, but their effect on health outcomes is less well studied.ObjectiveTo assess the effect of a multistate QI campaign (Project JOINTS, Joining Organizations IN Tackling SSIs) that used the Institute for Healthcare Improvement's Rapid Spread Network to promote adoption of evidence-based surgical site infection (SSI) prevention practices.MethodsWe analysed rates of SSI among Medicare beneficiaries undergoing hip and knee arthroplasty during preintervention (May 2010 to April 2011) and postintervention (November 2011 to September 2013) periods in five states included in a multistate trial of the Project JOINTS campaign and five matched comparison states. We used generalised linear mixed effects models and a difference-in-differences approach to estimate changes in SSI outcomes.Results125 070 patients underwent hip arthroplasty in 405 hospitals in intervention states, compared with 131 787 in 525 hospitals in comparison states. 170 663 patients underwent knee arthroplasty in 397 hospitals in intervention states, compared with 196 064 in 518 hospitals in comparison states. After the campaign, patients in intervention states had a 15% lower odds of developing hip arthroplasty SSIs (OR=0.85, 95% CI 0.75 to 0.96, p=0.01) and a 12% lower odds of knee arthroplasty SSIs than patients in comparison states (OR=0.88, 95% CI 0.78 to 0.99, p=0.04).ConclusionsA larger reduction of SSI rates following hip and knee arthroplasty was shown in intervention states than in matched control states.
| S-EPMC9290409 | biostudies-literature
Project description:BackgroundSurgical 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/purposesOur 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?MethodsIn 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.ResultsAmong 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).ConclusionsWe 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 evidenceLevel II, therapeutic study.
| S-EPMC7371089 | biostudies-literature
Project description:AimTo assess the effects of nasal decontamination on preventing surgical site infections (SSIs) in people who are Staphylococcus aureus carriers undergoing different types of surgeries and diverse measures of decolonization.MethodsRelevant randomized controlled trials (RCTs) were identified through systematic searches of the PubMed, Embase, Web of science, and the Cochrane Library databases. The risk ratios (RRs) and 95% confidence intervals (CIs) were calculated and the effects model was chosen according to the heterogeneity. Subgroup analyses were performed according to different types of surgeries and measures of decolonization that Staphylococcus aureus carriers were applied.ResultsTwenty RCTs published between 1996 and 2019 involving 10,526 patients were included. Pooled results showed that the overall SSIs and pulmonary surgery SSIs presented with a statistical difference in measures of nasal decontamination (RR = 0.59 and 0.47, respectively, both p < 0.01). However, the associations between nasal decolonization and increased risks of SSIs in orthopedics surgery or cardiovascular surgery remained insignificant in studies. As for the diverse measures of nasal decontamination, 50% used mupirocin, 15% used chlorhexidine, 30% used different types of antimicrobial drugs, and 5% use others. The SSIs rate were decreased after chlorhexidine (RR = 0.474, 95% CI 0.259-0.864), while no significant difference was shown in the use of mupirocin (RR = 0.871, 95% CI 0.544-1.394).ConclusionIt seems that nasal decolonization of Staphylococcus aureus may be associated with a reduction of SSIs in these patients, especially in patients who have been administered by pulmonary surgeries or treated with chlorhexidine.
| S-EPMC7392830 | biostudies-literature
Project description:BackgroundWhile 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.MethodsDecision 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.ResultsUse 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).ConclusionsDecolonization for Staphylococcus aureus prior to hip and knee replacements resulted in cost savings and fewer SSIs, and should be considered prior to these procedures.
| S-EPMC6625116 | biostudies-literature
Project description:BackgroundPopulation based surveillance of surgical site infections (SSIs) requires precise case-finding strategies. We sought to develop and validate machine learning models to automate the process of complex (deep incisional/organ space) SSIs case detection.MethodsThis retrospective cohort study included adult patients (age ≥ 18 years) admitted to Calgary, Canada acute care hospitals who underwent primary total elective hip (THA) or knee (TKA) arthroplasty between Jan 1st, 2013 and Aug 31st, 2020. True SSI conditions were judged by the Alberta Health Services Infection Prevention and Control (IPC) program staff. Using the IPC cases as labels, we developed and validated nine XGBoost models to identify deep incisional SSIs, organ space SSIs and complex SSIs using administrative data, electronic medical records (EMR) free text data, and both. The performance of machine learning models was assessed by sensitivity, specificity, positive predictive value, negative predictive value, F1 score, the area under the receiver operating characteristic curve (ROC AUC) and the area under the precision-recall curve (PR AUC). In addition, a bootstrap 95% confidence interval (95% CI) was calculated.ResultsThere were 22,059 unique patients with 27,360 hospital admissions resulting in 88,351 days of hospital stay. This included 16,561 (60.5%) TKA and 10,799 (39.5%) THA procedures. There were 235 ascertained SSIs. Of them, 77 (32.8%) were superficial incisional SSIs, 57 (24.3%) were deep incisional SSIs, and 101 (42.9%) were organ space SSIs. The incidence rates were 0.37 for superficial incisional SSIs, 0.21 for deep incisional SSIs, 0.37 for organ space and 0.58 for complex SSIs per 100 surgical procedures, respectively. The optimal XGBoost models using administrative data and text data combined achieved a ROC AUC of 0.906 (95% CI 0.835-0.978), PR AUC of 0.637 (95% CI 0.528-0.746), and F1 score of 0.79 (0.67-0.90).ConclusionsOur findings suggest machine learning models derived from administrative data and EMR text data achieved high performance and can be used to automate the detection of complex SSIs.
| S-EPMC10474760 | biostudies-literature
Project description:BackgroundSurgical site infections (SSI) are rare but severe complications after total joint arthroplasty (TJA). Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of SSI with Staphylococcus aureus (S. aureus).ObjectiveTo determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA.MethodsPatients scheduled for elective hip or knee TJA in 5 participating certified orthopedic centers were included between 2015 and 2018 into this before and after study. Data on patients, surgeries and infections were prospectively collected. CDC-criteria were used to define and categorize Infections within 90 days after surgery. From January 2017 on, patients received decolonization sets containing Polyhexanide. Patients performed a 5 day decolonization regimen starting 4 days prior to surgery which included wipes, nasal decontamination and oral solution.ResultsThirteen thousand, three hundred fifteen patients received TJA. During intervention 4437 decolonization sets were distributed among 7175 patients. Overall SSI rates increased from 0.68 /100 surgeries to 0.91/ 100 surgeries after implementation of the intervention (IRR 1.32; 95% CI 0.90-1.96). Time series analysis identified an increasing trend of SSI prior to the intervention. After implementation overall SSI rates plateaued. Regression analysis revealed surgery during intervention period to be an independent risk factor for developing a SSI (OR 1.34; 95%CI 1.18-1.53). Initial SSI rates due to S. aureus were 0.24/100 surgeries and decreased to 0.14/100 surgeries (IRR 0.57; 95% CI 0.25-1.22) after introduction of decolonization. Regression analysis revealed surgery during intervention period to be an independent protective factor for developing a SSI with S. aureus (OR 0.57, 95% CI: 0.33-0.99). Overall deep S. aureus SSI decreased significantly from 0.22/100 surgeries to 0.00/100 surgeries in patients adherent to protocol (IRR 0.00, 95% CI 0.00-.85).ConclusionUniversal decolonization with Polyhexanide did not reduce overall surgical site infections, but was effective in reducing Staphylococcus aureus - surgical site infections following elective joint arthroplasty. Polyhexanide could extend the list of alternatives to already established decolonization strategies.Trial registrationThe trial was registered at the German Registry for clinical studies www.drks.de ( DRKS00011505 ).
| S-EPMC7708093 | biostudies-literature