Risk of Surgical Site Infection in Elective Hip and Knee Replacements After Confirmed Eradication of MRSA in Chronic Carriers

      Abstract

      Background

      Methicillin-resistant Staphylococcus aureus (MRSA) is globally endemic and is a leading cause of surgical site infection (SSI). The purpose of this study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip or knee arthroplasty, who had confirmed eradication and to compare it with incidence of SSI in non-MRSA carriers.

      Methods

      This is a retrospective analysis of 6613 patients who underwent elective total hip arthroplasty (THA; n = 3347) and total knee arthroplasty (TKA; n = 3266) at our institution. A cohort of patients who were preoperatively colonized with MRSA was identified. We compared the infection rates with non-MRSA carriers.

      Results

      We had a colonization rate of 1.3% (83 patients). A total of 79 patients had confirmed eradication of carrier status before surgical intervention. Of these, 38 were THAs and 41 were TKAs. Five of 79 patients (6.32%; 95% confidence interval [CI]: 2.35%-14.79%) had “deep SSI” within 1 year of surgery. There were 2 MRSA infections in THAs (relative risk 4.46; 95% CI: 1.12-17.82). There were 2 MRSA and 1 methicillin-sensitive Staphylococcus aureus infections in TKAs (relative risk 5.61; 95% CI: 1.81-17.38). A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% in THAs and 1.3% in TKAs over the same period.

      Conclusion

      In spite of a selective treatment program for carriers and confirmed eradication, there is still a significantly increased risk of SSI in MRSA-colonized patients undergoing hip or knee arthroplasties.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986-April 1997, issued May 1997: a report from the NNIS System.
        Am J Infect Control. 1997; 25: 477-487
        • Whitehouse J.D.
        • Friedman N.D.
        • Kirkland K.B.
        • Richardson W.J.
        • Sexton D.J.
        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
        • Jevons M.P.
        Celbenin resistant staphylococci.
        BMJ. 1961; 1: 124-125
        • Blumberg H.M.
        Community-acquired versus healthcare-associated methicillin-resistant (MRSA) infections: is the distinction blurring?.
        Clin Updates Infect Dis. 2009; 12: 1-6
        • Kluytmans J.
        • Struelens M.
        Methicillin resistant Staphylococcus aureus in the hospital-clinical review.
        BMJ. 2009; 338: b364
        • Marcotte A.L.
        • Trzeciak M.A.
        Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics.
        J Am Acad Orthop Surg. 2008; 16: 98-106
        • Rozgonyi F.
        • Kocsis E.
        • Kristóf K.
        • Nagy K.
        Is MRSA more virulent than MSSA?.
        Clin Microbiol Infect. 2007; 13: 843-845
        • Kocsis E.
        • Kristóf K.
        • Hermann P.
        • Rozgonyi F.
        A comparative review on the pathogenicity and virulence factors of meticillin-resistant and meticillin-susceptible Staphylococcus aureus.
        Rev Med Microbiol. 2010; 21: 31-37
        • Ando E.
        • Monden K.
        • Mitsuhata R.
        • Kariyama R.
        • Kumon H.
        Biofilm formation among methicillin-resistant Staphylococcus aureus isolates from patients with urinary tract infection.
        Acta Med Okayama. 2004; 58: 207-214
        • Salgado C.D.
        • Farr B.M.
        • Calfee D.P.
        Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors.
        Clin Infect Dis. 2003; 36: 131-139
        • DeLeo F.R.
        • Otto M.
        • Kreiswirth B.N.
        • Chambers H.F.
        Community-associated methicillin-resistant Staphylococcus aureus.
        Lancet. 2010; 375: 1557-1568
        • Wang R.
        • Braughton K.R.
        • Kretschmer D.
        • Bach T.H.
        • Queck S.Y.
        • Li M.
        • et al.
        Identification of novel cytolytic peptides as key virulence determinants for community-associated MRSA.
        Nat Med. 2007; 13: 1510-1514
        • Kobayashi S.D.
        • DeLeo F.R.
        An update on community-associated MRSA virulence.
        Curr Opin Pharmacol. 2009; 9: 545-551
        • Shukla S.
        • Nixon M.
        • Acharya M.
        • Korim M.T.
        • Pandey R.
        Incidence of MRSA surgical-site infection in MRSA carriers in an orthopaedic trauma unit.
        J Bone Joint Surg [Br]. 2009; 91-B: 225-228
        • Rao N.
        • Cannella B.
        • Crossett L.S.
        • Yates A.J.
        • McGough R.
        A preoperative decolonization protocol for Staphylococcus aureus prevents orthopaedic infections.
        Clin Orthop Relat Res. 2008; 466: 1343-1348
        • Hacek D.M.
        • Robb W.J.
        • Paule S.M.
        • Kudrna J.C.
        • Stamos V.P.
        • Peterson L.R.
        Staphylococcus aureus nasal decolonization in joint replacement surgery reduces infection.
        Clin Orthop Relat Res. 2008; 466: 1349-1355
      2. World Health Organisation guidelines for safe surgery, 2009.
        ([accessed 25.02.11])
        • R Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2015 ([accessed 06.16])
        • Garrouste-Orgeas M.
        • Timsit J.F.
        • Kallel H.
        • Ben Ali A.
        • Dumay M.F.
        • Paoli B.
        • et al.
        Colonization with methicillin resistant Staphylococcus aureus in ICU patients: morbidity, mortality and glycopeptides use.
        Infect Control Hosp Epidemiol. 2001; 22: 687-692
        • Mest D.R.
        • Wong D.H.
        • Shimonda K.J.
        • Mulligan M.E.
        • Wilson S.E.
        Nasal colonization with methicillin-resistant Staphylococcus aureus on admission to the surgical intensive care unit increases the risk of infection.
        Anesth Analg. 1994; 78: 644-650
        • Coello R.
        • Glynn J.R.
        • Gaspar C.
        • Picazo J.J.
        • Fereres J.
        Risk factors for developing clinical infection with methicillin-resistant Staphylococcus aureus (MRSA) amongst hospital patients initially only colonized with MRSA.
        J Hosp Infect. 1997; 37: 39-46
        • Kim D.H.
        • Spencer M.
        • Davidson S.M.
        • Li L.
        • Shaw J.D.
        • Gulczynski D.
        • et al.
        Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery.
        J Bone Joint Surg [Am]. 2010; 92-A: 1820-1826
        • Chen A.F.
        • Heyl A.E.
        • Rao N.
        • Klatt B.A.
        Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients.
        J Arthroplasty. 2013; 28: 18-20
        • Verhoeven P.O.
        • Berthelot P.
        • Chapelle C.
        • Gagnaire J.
        • Grattard F.
        • Pozzetto B.
        • et al.
        Letter to the editor: Staphylococcus aureus screening and decolonization in orthopaedic surgery and reduction of surgical site infections.
        Clin Orthop Relat Res. 2013; 471: 3709-3711
        • Sousa R.J.G.
        • Barreira P.M.B.
        • Leite P.T.
        • Santos A.C.
        • Ramos M.H.
        • Oliveira A.F.
        Preoperative Staphylococcus aureus screening/decolonization protocol before total joint arthroplasty—results of a small prospective randomized trial.
        J Arthroplasty. 2016; 31: 234-239
        • Ramos N.
        • Stachel A.
        • Phillips M.
        • Vigdorchik J.
        • Slover J.
        • Bosco J.A.
        Prior Staphylococcus aureus nasal colonization: a risk factor for surgical site infections following decolonization.
        J Am Acad Orthop Surg. 2016; 24: 880-885
        • Murphy E.
        • Spencer S.J.
        • Young D.
        MRSA colonisation and subsequent risk of infection despite effective eradication in orthopaedic elective surgery.
        J Bone Joint Surg [Br]. 2011; 93-B: 548-551
        • Finkelstein R.
        • Rabino G.
        • Mashiah T.
        • Bar-El Y.
        • Adler Z.
        • Kertzman V.
        • et al.
        Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections.
        J Thorac Cardiovasc Surg. 2002; 123: 326-332
        • Bratzler D.W.
        • Houck P.M.
        Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project.
        Am J Surg. 2005; 189: 395-404
        • Ritter M.A.
        • Olberding E.M.
        • Malinzak R.A.
        Ultraviolet light during orthopaedic surgery and the rate of infection.
        J Bone Joint Surg [Am]. 2007; 89-A: 1935-1940
        • Roberts V.I.
        • Esler C.N.
        • Harper W.M.
        A 15-year follow-up of 4606 primary total knee replacements.
        J Bone Joint Surg [Br]. 2007; 89-B: 1452-1456
        • Kalmeijer M.D.
        • Coertjens H.
        • van Nieuwland-Bollen P.M.
        • Bogaers-Hofman D.
        • de Baere G.A.
        • Stuurman A.
        • et al.
        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
        • Kalmeijer M.D.
        • van Nieuwland-Bollen E.
        • Bogaers-Hofman D.
        • de Baere G.A.
        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
        • 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
        • Perl T.M.
        • Golub J.E.
        New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage.
        Ann Pharmacother. 1998; 32: S7-S16
        • Wenzel R.P.
        • Perl T.M.
        The significance of nasal carriage of Staphylococcus aureus and the incidence of postoperative wound infection.
        J Hosp Infect. 1995; 31: 13-24
        • Price C.S.
        • Williams A.
        • Philips G.
        • Dayton M.
        • Smith W.
        • Morgan S.
        Staphylococcus aureus nasal colonization in preoperative orthopaedic outpatients.
        Clin Orthop Relat Res. 2008; 466: 2842-2847
        • Yano K.
        • Minoda Y.
        • Sakawa A.
        • Kuwano Y.
        • Kondo K.
        • Fukushima W.
        • et al.
        Positive nasal culture of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infection in orthopedics.
        Acta Orthop. 2009; 80: 486-490
        • Berthelot P.
        • Grattard F.
        • Cazorla C.
        • Passot J.P.
        • Fayard J.P.
        • Meley R.
        • et al.
        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
        • Uçkay I.
        • Lübbeke A.
        • Harbarth S.
        • Emonet S.
        • Tovmirzaeva L.
        • Agostinho A.
        • et al.
        Low risk despite high endemicity of methicillin-resistant Staphylococcus aureus infections following elective total joint arthroplasty: a 12-year experience.
        Ann Med. 2012; 44: 360-368
        • Valdés C.
        • Tomás I.
        • Alvarez M.
        • Limeres J.
        • Medina J.
        • Diz P.
        The incidence of bacteraemia associated with tracheal intubation.
        Anaesthesia. 2008; 63: 588-592
        • Gilpin D.F.
        • Small S.
        • Bakkshi S.
        • Kearney M.P.
        • Cardwell C.
        • Tunney M.M.
        Efficacy of a standard methicillin-resistant Staphylococcus aureus decolonisation protocol in routine clinical practice.
        J Hosp Infect. 2010; 75: 93-98
        • Phillips M.
        • Rosenberg A.
        • Shopsin B.
        • Cuff G.
        • Skeete F.
        • Foti A.
        • et al.
        Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone iodine solution.
        Infect Control Hosp Epidemiol. 2014; 35: 826-832
        • Gopal Rao G.
        • Michalczyk P.
        • Nayeem N.
        • Walker G.
        • Wigmore L.
        Prevalence and risk factors for methicillin-resistant Staphylococcus aureus in adult emergency admissions: a case for screening all patients?.
        J Hosp Infect. 2007; 66: 15-21
        • Nathwani D.
        Impact of methicillin-resistant Staphylococcus aureus infections on key health economic outcomes: does reducing the length of hospital stay matter?.
        J Anti-microb Chemother. 2003; 51: 37-44
        • Bozic K.J.
        • Ries M.D.
        The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization.
        J Bone Joint Surg Am. 2005; 87: 1746-1751